Summary: There was fault by the Council in the way it considered a home to school transport application made on SEN/mobility grounds which, on the balance of probabilities, led to transport being wrongly refused. This has caused injustice and inconvenience to the family. Recommendations for an individual remedy and service improvements are made.

The complaint

1. Mrs A complains about a decision by the Council’s transport team and a transport appeal panel not to award free home to school transport to her daughter (whom I shall refer to as B).

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
4. Appeal panels must follow the law when considering an appeal. The Ombudsman does not question the merits of decisions properly taken. An independent panel is entitled to come to its own judgment about the evidence it hears.
5. We may investigate matters coming to our attention during an investigation if we consider that a member of the public who has not complained may have suffered an injustice as a result. (Local Government Act 1974, section 26D and 34E, as amended)
6. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

7. I have considered information provided by Mrs A and the Council including:
• Mrs A’s application for transport support
• Mrs A’s appeal at stage one and stage two and supporting evidence
• The Council’s decision letters
• The Council’s response to enquiries I raised.
8. I have considered relevant law and guidance including:
• Education Act 1996
• Home to School Travel and Transport Statutory Guidance
• The Ombudsman’s guidance:
1. ‘Principles of Good Administrative Practice’ (2018)
2. ‘All aboard? Navigating School Transport Issues’ (March 2017)
3. Guidance on Remedies.
9. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Office for Standards in Education, Children’s Services and Skills (Ofsted), we will share this decision with Ofsted.
10. Mrs A and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

The law and relevant guidance

11. Section 508B of the Education Act 1996 (‘The Act’) says councils must provide free school transport to eligible children. The term 'eligible' means children of compulsory school age who meet certain criteria as set out in Schedule 35B of the Act.
12. Eligible children fall into four categories:
• Children with special educational needs (SEN) or a mobility difficulty and cannot reasonably be expected to walk to school where the school is within the statutory walking distance.
• Children whose route to school is unsafe.
• Children who live outside the statutory walking distance to school (currently 2 miles of under 8 years and 3 miles if between 8-16 years).
• Children from low income families (on free school meals or in receipt of maximum working tax credit)
13. Councils also have discretion under s.508C of the Act to make provision for non-eligible children where they consider it ‘necessary’ to facilitate the child’s attendance at school. A common situation where this may arise is where a child has a disabled parent.
14. The Government has issued statutory guidance ‘Home to School travel and transport’ for local authorities’ (‘the Guidance’). Councils must have regard to the Guidance when carrying out their duties. This means Councils can depart from the Guidance, but if they do, they must have a good reason for doing so.
15. The Guidance says eligibility under SEN / mobility grounds should ‘be assessed on an individual basis to identify their particular travel requirements’ and that the statutory walking distance is not relevant for children eligible due to SEN or mobility.
16. If the child can physically walk the distance but is unsafe to do so, the Council must consider:
1. whether the child could reasonably be expected to walk if accompanied and, if so,
2. whether the child’s parent can reasonably be expected to accompany the child.

17. When considering whether a child’s parent can reasonably be expected to accompany the child on the journey to school a range of factors may need to be taken into account, such as the age of the child and whether one would ordinarily expect a child of that age to be accompanied. The general expectation is that a child will be accompanied by a parent where necessary, unless there is a good reason why it is not reasonable to expect the parent to do so.
18. Councils should have in place both complaints and appeals procedures for parents to follow should they have cause for complaint about the service or wish to appeal about the eligibility of their child for travel support. The Government recommends a two-stage review/appeals process for Councils to follow:
• Stage one of the recommended appeal process is a review by a senior officer who provides a ‘detailed written decision’ setting out:
1. The nature of the decision reached
2. How the review was conducted
3. Information about other agencies consulted as part of the review
4. The factors considered and the rationale reached.
• Stage two of the recommended appeal process is review by an independent appeal panel which considers written and verbal representations from both the parent and the officers involved and again provides a detailed written decision. Panel members must be independent of the original decision-making process but do not have to be independent of the Council.

The Council’s 2015 transport policy

19. The Council relies on its 2015 policy. It updated this in 2017, but the 2017 policy was later withdrawn and the Council reverted to its 2015 policy.
20. The Council acknowledged in its response to my enquiries that the withdrawal of the 2017 policy happened during the timeline of Mrs A’s case and that referring to two policies will have inadvertently caused confusion for which it apologises.
21. The Council’s policy says transport will be provided on SEN/mobility grounds to:
• Children with an EHC plan living within statutory walking distance if:
1. The need for support is apparent from their EHC plan, and
2. The child is attending the nearest qualifying school as named on the EHC plan; or
• Children without an EHC plan if:
1. They have a disability, mobility, congenital or permanent medical condition that means they cannot reasonably be expected to walk to school, and
2. They attend their nearest qualifying school, and
3. They are able to avail themselves of all or most of the education available in school, and
4. Their application is supported by written evidence from a qualified medical professional, and
5. Parents are unable to provide their own transport.

The facts

The transport application

22. Mrs A has four children. B has anxiety, learning difficulties and a communication disorder and has attended a specialist resourced provision at a mainstream secondary school since September 2019. B’s school is 1.8 miles from her home. B starts school at 8.20am.
23. B has one sibling with special educational needs (SEN) who attends a resourced provision at a different secondary school 3.5 miles from their home and 3 to 4 miles from B’s school. This child requires Mrs A’s supervision to get ready for school and meet the school bus at 8am as well as after school. This means Mrs A cannot leave the house with B before 8am.
24. B has two other siblings who attend primary school and a nursery close to the family home. Their school starts at 8.40am. Mrs A gave the walking distance between B’s school and home as 38 to 40 minutes and between B’s school and the primary school as 32 minutes. Mrs A did not drive at the time of the complaint and her partner left for work at 7am so was unable to help with getting the children to school.
25. B has an Education, Health and Care plan (EHCP) maintained by the Council. This was finalised to name her secondary school in March 2019. The EHCP refers to B’s SEN and anxiety but does not specifically address whether B has more difficulties with walking or using public transport than others of the same age.
26. Mrs A did not apply for transport support for B until September 2019 after B had started at her new school. Mrs A described on the application form that B was distressed about travelling, experiencing panic attacks and refused to travel without Mrs A accompanying her. Mrs A explained accompanying B was problematic because of the need to support B’s siblings getting to school. Mrs A applied for council transport support for B on the grounds her SEN and anxiety affected B’s ability to travel independently.
27. The application form did not have a section for parents to explain any factors that might make it difficult for them to accompany a child to school. The form did not indicate that parents needed to provide medical or supporting evidence but did prompt parents to provide further details if they had ticked any boxes indicating particular needs of the child.
28. On 27 September 2019 an officer checked B’s eligibility and noted:
• The school was named on B’s EHC plan
• The school was 1.8 miles from home
• Transport was refused as ‘under distance, need not apparent from EHCP, no recorded mobility problems’.
29. The Council’s decision letter of the same date gave two reasons for refusal:
• Distance below statutory walking distance
• ‘It is our assessment that B has the capacity to undertake this journey accompanied as necessary by a responsible adult’.
30. The letter advised Mrs A of the right of appeal but did not give any further advice about what evidence the Council would need to see to alter its view.

The stage one appeal

31. Mrs A appealed the decision on 14 October 2019 on the basis:
• The statutory walking distance did not apply to an application made on SEN / mobility grounds
• B did have mobility problems caused by her SEN and received low rate mobility disability living allowance (and middle rate care component)
• B’s EHCP did not reflect the extent of her difficulties, her worsening anxiety or address her transport needs
• The family was due to move house shortly, which would require a longer journey to school for B
• The Council had not considered if it was reasonable for an adult to accompany B. Mrs A repeated her evidence about having to get four children to three different places by herself. Mrs A set out the start, finish and journey times and explained how it was impossible for her to get all the children to their schools on time. Mrs A provided evidence from B’s school of her anxiety.
32. The Council sent Mrs A its stage one appeal decision letter on 5 November 2019. The review officer said they were ‘satisfied the original assessment was being carried out fairly and within the guidelines of the policy’. The Council relied on its 2015 transport policy and the Education and Inspections Act 2006. The reviewer said having an EHCP did not guarantee an award of transport and the Council would expect Mrs A to be able to accompany B to and from school ‘as any other parent of children in Leeds would do’. The reviewer said Mrs A’s other childcare commitments could not be taken into account by the Council. It said if Mrs A considered B’s EHCP was out of date she should ask for eligibility to be reassessed. The letter said Mrs A could appeal to stage two ‘if you feel your circumstances are exceptional’.

The stage two appeal panel

33. Mrs A appealed to stage two and a charity caseworker wrote a supporting letter detailing why it considered the Council’s decision to be flawed. The charity referred to confusion whether the Council was relying on its 2015 or 2017 policy. It also said that it was unclear how the Council had ‘assessed’ B’s capacity to walk to school and that the Council had stated the relevant law incorrectly. It said most children B’s age would not need to be accompanied; her family were being put at a disadvantage to their peers and the policy did not comply with the Council’s equality obligations. Mrs A provided a supporting letter from B’s general practitioner (GP).
34. The Clerk’s notes of the appeal panel show the panel considered the following relevant points:
• That the anticipated house move was not relevant to the appeal as Mrs A would need to reapply once the house purchase was complete
• That the Council had referred to the wrong policy in correspondence but this did not alter the basis of decision making for this appeal
• That B’s EHCP did not include reference to travel needs and Mrs A would need to request a review to amend the EHCP if she felt B’s needs had significantly changed
• The panel decided B was not eligible for transport support as while the panel understood the difficulty of getting four children to different schools this was not felt to be ‘exceptional’.
35. The decision letter following the appeal stated:
• The panel had declined support and transport would remain a parental responsibility
• The panel considered there was limited evidence B’s SEN and anxiety affected B’s ability to travel to school ‘independently and safely accompanied as necessary by an adult’
• Mrs A’s difficulties in getting four children to different schools was not exceptional to warrant the award of transport support
• The panel had noted the EHCP did not reference travel and recommended B’s journey to and from school be considered when the Plan was next updated

Ombudsman’s enquiries

36. I raised enquiries of the Council which responded with the following information:
• The Council’s assessment of a child’s ability to walk to school, accompanied or otherwise, is based on information contained within an EHCP and any supplementary information supplied by the applicant, such as a medical report.
• Section 9.215 of the SEND Code of Practice states that transport should be recorded in the EHCP only in exceptional cases where the child has particular transport needs. However, EHCP’s routinely include information that may indicate a need for transport assistance.
• It was an observation, not a criticism, by the appeal panel that there was nothing in the EHCP to indicate that B was unable to walk to school. They did advise, however, that Mrs A should raise this during the next EHCP review if she felt it applicable. The panel also noted the letter provided by the family GP but felt this held very limited weight as it provided no evidence of a medical assessment having taken place, and appeared to be limited to the GP restating Mrs A’s personal views.
• ‘In the absence of any evidence to the contrary’ the panel were satisfied that B was able to walk to school and the Council did not consider ‘there was an obligation on the council’s part to look for evidence in support of the parent’s claim’.
• Where there is information suggesting barriers to being able to walk to school, further investigation is carried out by SEND transport assessors, which may include a home visit.
• The Council’s view was that B could not walk independently but could walk if accompanied. This view was ‘based on the absence of any information to the contrary recorded in the EHCP and the lack of weight in the medical evidence provided by the GP’.
• With regard to equality considerations, there is no upper age limit at which the Council automatically assumes children should no longer be accompanied. The Council considers its policy meets its legal requirements around equality and discrimination and is line with many other councils.
• Because it necessarily requires case-by-case judgement to be exercised about what constitutes a ‘good reason’ as to why a parent can’t ‘reasonably’ be expected to accompany their child, the council does not consider it would be helpful to attempt to set out in the policy eligibility criteria that would apply.
• Any need for assistance arising from a parent’s inability to provide accompaniment must take into account a variety of factors including: the child’s abilities; the range of challenges facing the parent; the extent to which the challenges facing a family compare with those of other families; and what other reasonable options a parent tells the Council have been explored.
• In this case the view was that the barriers to providing accompaniment were essentially the need to juggle the morning travel arrangements of several children. No information was provided about what other options had been explored and disregarded as unworkable. It is not felt that a reliance should be placed on the council to know the potential solutions uniquely available to every individual family. The panel members confirmed they took the view that in this particular case it was reasonable to expect Mrs A to accompany B if necessary, and to also make the arrangements for her other children.
• The Council was wrong to reference statutory walking distance in its decision making as it did not apply to this case. The Council acknowledged this will have caused confusion and apologises for this fact.
• The Council acknowledges that Mrs A found its statement that it would expect her to accompany B ‘as any other parent of children in Leeds would do” distasteful and hurtful and that it made her feel that the Council considered her to be lazy and unconcerned about B’s welfare. The Council apologises that the form of words used was inconsiderate and did not meet its values.
37. The Council told me Mrs X had reapplied for transport support in March 2020 after moving house and it has awarded support from May 2020 on the basis that:
• This was a more complex journey
• The Assessment Officer had liaised directly with the Educational Psychologist (EP) who provided evidence B’s anxieties had increased since the last assessment
• That B’s EHCP would include an outcome of her working towards travelling independently.

Analysis

Fault

38. The Council’s documents refer to the following reasons for refusing to award transport to B:
1. That she lived within statutory walking distance
2. That transport needs were not apparent from, and mobility needs not recorded in, the EHCP
3. That it had assessed ‘that B has the capacity to undertake this journey accompanied as necessary by a responsible adult’
4. That it was ‘satisfied the original assessment was being carried out fairly and within the guidelines of the policy’
5. That it was reasonable for Mrs A to accompany B ‘as any other parent...would do’
6. That other childcare commitments could not be taken into account as a reason not to accompany
7. That the EHCP would need to be amended to consider any change in needs
8. That Mrs A would need to have ‘exceptional’ circumstances for an award to be made. Having to manage the needs of different children was not exceptional as it was something many parents had to do.
9. That the Council would assume a child could walk to school unless there was evidence to the contrary; but there was no obligation for the Council to look for evidence to support a claim.
39. The Council has acknowledged Reason A (statutory walking distance) was irrelevant and it was fault to refuse the original application on this basis.
40. As B had an EHCP and attended the nearest qualifying school, the Council’s policy was to provide transport if this was evident from her EHCP. As her transport needs were not apparent from her EHCP, support was refused (Reason B). However, the reason B’s needs were not apparent from the EHCP was not because she did not potentially have needs that might affect her ability to travel to school but because the EHCP had not considered them. Mrs A provided evidence B was in receipt of disability living allowance for mobility before her EHCP was written.
41. If the Council wishes to rely on the EHCP as evidence for awarding transport it is imperative that transport needs are discussed with the family and professionals during the writing of the EHCP. As this did not happen in B’s case, B should not have been penalised because the Council has failed to follow its own process. It was fault for the Council to rely on Reason B as a basis for declining the application when the reason transport needs were not recorded was due to its own actions.
42. Given B’s EHCP was deficient as far as transport needs were concerned the Council should have considered B’s application as though she had no EHCP. Its approach would then have been to consider whether B:
1. had a disability or condition that meant she could not reasonably be expected to walk to school, and
2. attended her nearest qualifying school, and
3. could avail herself of all or most of the education available in school, and
4. her application was supported by written evidence from a qualified medical professional, and
5. her parents were unable to provide their own transport.
43. I find that while the policy refers to the need for medical evidence to support an application for a child without an EHCP, there is no reference of this on the application form to prompt parents to provide it. This is fault. The Ombudsman expects Councils to be open about policies and procedures and for any advice provided to be clear, accurate and complete. This includes stating the criteria for decision making and ensuring decisions and actions are fair. (Principles of Good Administrative Practice) I find that while Ms A was told an absence of evidence in the EHCP meant her application did not succeed, at no point did the Council advise Ms A about what evidence was required for her application to be successful. Ms A would have had no reason to consider the section of the policy dealing with children who did not have an EHCP.
44. The Council told me it does not consider ‘there was an obligation on the council’s part to look for evidence in support of the parent’s claim’ and so it could decline applications on the basis of an ‘absence of information’ (Reason I). I disagree. S.508B Education Act 1996 says councils must make transport arrangements for eligible children to attend school. An eligible child is defined in Schedule 35B and includes children with SEN, a disability or mobility problems who cannot reasonably be expected to walk to school. It is for the Council to determine if a child is eligible, that is the onus is on the Council to determine whether SEN, disability or mobility problems mean it is not reasonable to expect a child to walk to a school within statutory walking distance. This is confirmed in the Guidance which is clear that for applications on SEN/disability/mobility grounds the onus is on the Council: ‘Eligibility for such children is to be assessed on an individual basis to identify their particular transport requirements’.
45. The section of the Guidance on eligible children does not set out how councils should assess eligibility, but the Government’s expectations can be inferred from the section on appeals. This says appeal decisions should set out the rationale for the decision and set out information about what other departments and / or agencies were consulted as part of the Council’s process. The expectation is therefore that Councils should consult other agencies and gather evidence where necessary to complete the assessment.
46. There is nothing in the law or guidance which prevents councils asking parents to provide information or evidence that may be in parents possession, but there is no requirement for parents to seek medical reports or advice, which are often not within a parents gift to obtain.
47. It is also not the case there was no supportive evidence. Mrs A did provide evidence from the school, GP and the disability living allowance award. The Council has explained why it did not accept the GP advice but not referred to the other evidence. If the Council considered it required more specific medical evidence about B’s needs to determine her eligibility then it was for the Council to obtain it.
48. An ‘absence’ of information cannot ever amount to a ‘satisfactory assessment’ of eligibility under s.508B. I find no satisfactory ‘assessment’ of B under s.508B was carried out and the application should not have been refused on this basis (Reasons C, D and I).
49. Mrs A never claimed that B could not travel to school if accompanied by an adult. The Council told me in its response to my enquiries it accepted this and it also accepted B did need to be accompanied. It is therefore unclear why any assessment of B’s ‘capacity’ to walk to school was required or why the wording of her EHCP was relevant if the Council accepted Mrs A’s evidence from the start. The only issue for the Council was whether Mrs A had a ‘good reason’ not to accompany B or (under its policy wording) B’s family was ‘unable to provide their own transport’.
50. The Council failed to consider the matter of accompaniment at the original decision or at stage one, although this was the only matter which needed to be determined. This was fault. Whether it was reasonable for Mrs A to accompany B was considered for the first time at the appeal hearing.
51. The Council told me Mrs A’s application was refused because she had not provided evidence of all the alternative options she had explored to get her four children to school and why these were disregarded as unworkable. However, these were not the reasons given to Mrs A at the time. It was never explained to Mrs A that she needed to provide evidence of options considered but disregarded. There is no mention of this criteria in the policy, the application form, at the appeal hearing or in the decisions. This was unfair and was fault. Mrs A was entitled to know the criteria for the Council’s decision making. Without this information her application, and any others like it, were doomed to fail.
52. The Council told Mrs A her application was refused because there was an expectation all parents accompany their children regardless of competing childcare obligations and that her situation was not ‘exceptional’ compared to other parents (Reasons E, F and H).
53. The Guidance says: ‘The general expectation is that a child will be accompanied by a parent where necessary, unless there is a good reason why it is not reasonable to expect the parent to do so’. The Guidance does not say childcare commitments are excluded from being a ‘good reason’ not to accompany and it was fault for the Council to say that other childcare commitments were irrelevant or not sufficiently ‘exceptional’.
54. The Council and appeal panel failed to consider Mrs A’s particular circumstances and apply the correct test of whether it was reasonable for her to accompany all her children to school or whether there was a ‘good reason’ why this was not possible. Instead the Council’s panel set a much higher test of exceptionality. This was fault and casts doubt on the decision reached.
55. The panel should have considered how long the journey to three places would take Mrs A, whether it would mean some of her children missing part of their school day or whether there were safeguarding considerations if Mrs A was not home in time to meet the school bus of another child with SEN. It did not consider whether there were other options available to Mrs A or if it was reasonable for her to disregard other options. This was fault.
56. The Council says it has no upper age limit as to when it would expect a child to be accompanied. While Mrs A has raised that this approach will disproportionately affect children with SEN or disabilities, the Council is correct to say that in recent years many other councils have taken a similar approach. Whether this balance between resources and families amounts to discrimination or a breach of the public sector equality duty would be a matter for the courts, not the Ombudsman to determine. Our approach is to check that Councils have considered the individual circumstances in each case.
57. It was fault for the Council and appeal panel to suggest that B’s transport needs could only be reconsidered when the EHCP was updated (Reason G). The EHCP and transport assessments are separate processes governed by different legislation and imposing two separate legal duties on the Council. Eligibility for transport is to be assessed at the time a transport application is received, not the time when an EHCP is written. While EHCPs may provide useful information to support a transport application they can never be definitive as needs may have changed since the Plan was written. There was no legal basis for the Council to suggest B had to wait for an EHCP review before new medical evidence supporting a transport application could be considered.
58. B has now been awarded transport after moving house. It is not clear to me that anything substantially changed in relation to B’s eligibility between the appeal panel in January 2020 and the new application being submitted in March 2020. The Council told me transport was awarded because of the more complex journey and because EP advice supported B’s anxiety had increased since the last assessment. I assume the Council is referring here to the EHC assessment, as the Council did not carry out an assessment or seek EP advice at the time of the transport application.
59. As transport was refused on the basis of Mrs A accompanying B, and the Council’s approach was to expect all parents to accompany, then complexity of the journey does not explain the Council’s new decision. Complexity of the journey did not feature as a consideration in any of the decisions between November 2019 and January 2020 or in the Council’s policy. I also cannot see that the Council can claim B’s anxiety had increased since January 2020, not September 2019 as Mrs A claimed, when it did not gather evidence about anxiety in 2019. It is more likely that Mrs A’s second application was successful because the Council obtained professional advice of B’s needs in 2020 that it failed to obtain during the first application.
60. I can only assume that the Council has now accepted it was not reasonably practicable for Mrs A to accompany B for the same reasons that Mrs A gave in the first application.

Injustice

61. The fault in the way the Council and Panel considered Mrs A’s first application casts doubt on the decision the Council reached.
62. I find that had the Council correctly considered the first transport application, it would, on the balance of probabilities, have reached the same decision that it did in March 2020 and granted B transport.
63. I find that fault by the Council has:
• Caused unnecessary stress and anxiety to Mrs A and B
• Led to Mrs A incurring travel costs when free home to school transport would, on the balance of probabilities, have been in place from the start of October 2019
• Caused Mrs A additional time and trouble pursuing her case though the appeal and complaint procedures.

Fault and injustice to others

64. The Council has provided various reasons for refusing transport to Mrs A some of which were not relevant to her situation and some which did not correctly reflect the law and guidance. It is likely that the Council has made similar errors in other cases in that:
• It has expected parents to provide evidence that may not be readily available to them rather than seeking this itself
• It has not clearly explained to parents the criteria or standard of evidence it uses to decide eligibility
• Its policy, application form and decision letters do not explain to parents what evidence the Council would need to see to award transport on SEN/disability/mobility grounds or when deciding if parental accompaniment is reasonably practicable.
• It has placed the onus on families to prove their case to a higher evidential standard than the law provides for.

Agreed action

65. Within four weeks of my final decision:
• The Council will pay Mrs A £10 per school day from 7 October 2019 until the date transport started to be provided in May 2020 to acknowledge the time and trouble caused to her by the Council’s fault. For clarity this applies to each day the school was open and B was eligible to attend.
• The Council will pay B £250 to acknowledge the impact on her of not being provided with door to door transport
• The Council will apologise to Mrs A for the faults identified.
66. Within eight weeks of my final decision:
• the Council will review its application form and decision letters to ensure that they are clear and transparent about the evidence parents need to provide for a claim to be successful
• the Council will provide updated guidance to transport officers, reviewers and panel members about the law and guidance in relation to applications made on SEN/mobility grounds and the correct legal test for considering accompaniment by parents.

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Final decision

67. I have completed my investigation. There was fault by the Council in the way it considered a home to school transport application made on SEN/mobility grounds which, on the balance of probabilities, led to transport being wrongly refused. This has caused injustice and inconvenience to the family.

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Investigator's decision on behalf of the Ombudsman