Summary: Miss X complains about delays in the Council completing the annual review of her child, Z’s, Education, Health and Care Plan and failure by the Council to arrange suitable education for Z during the 2021/22 academic year. The Council accepted there were significant delays in the annual review process and that it failed to provide a suitable education. We also find the Council failed to carry out two key assessments by its social care team and obtain advice from a social care officer during the annual review. To remedy the injustice caused to Miss X and Z, the Council has agreed to apologise to Z and Miss X, make several financial payments, carry out the social care assessments now and make certain service improvements.

The complaint

1. The complainant, Miss X, complains the Council:
1. failed to complete her daughter, Z’s 2021/22 annual review and issue an amended Education, Health and Care Plan (EHC Plan) without delay. Miss X says the Council held an annual review meeting on 9 September 2021, but the Council still has not issued a final amended EHC Plan;
2. delayed in carrying out an Educational Psychologist assessment and SEN Specialist Services (SENSS) assessment;
3. failed to communicate with Miss X and consistently respond to her contact since the annual review meeting in September; and,
4. failed to put in place suitable alternative provision since January 2022 while the annual review was completed and a placement found. Miss X says there is some provision in place through an alternative provision provider, Alternative Provision Provider One, commissioned by the Council, but this focuses on Z’s reengagement with education.
2. Miss X says the Council’s failure to do what is required of it causes Z a great deal of stress and has affected her ability to engage in the provision in place with Alternative Provision Provider One. She says the situation has significantly affected Z’s depression and her mental and emotional wellbeing.
3. Miss X says Z has missed out on a great deal of education, which has also significantly affected her family. She says Z is not receiving any emotional or social support, which has left her isolated, including from her friends.
4. Miss X says her own mental health and wellbeing have been affected by the Council’s action.

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The Ombudsman’s role and powers

5. 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)
6. If we are satisfied with an organisation’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 spoke with Miss X about her complaint. I considered the information and documents that Miss X and the Council sent me.
8. Miss X and the Council had an opportunity to comment on my draft decision. I considered all comments before making a final decision.
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.

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What I found

What should have happened

Education, Health and Care Plans

10. A child with special educational needs may have an Education, Health and Care (EHC) plan. This sets out the child’s needs and what arrangements should be made to meet them. The EHC plan is set out in sections. We cannot direct changes to the sections about education, or name a different school. Only the tribunal can do this.
11. We can consider the other sections of an EHC plan. We do this by checking the Council followed the correct process, and took account of all relevant information, in deciding what to include. If we find fault affected the outcome, we may ask the Council to reconsider. We will not usually substitute our judgement for the judgement of professionals.
12. The council has a duty to secure the specified special educational provision (SEP) in an EHC plan for the child or young person. (Children and Families Act, Section 42) The Courts have said this duty to arrange provision is owed personally to the child and is non-delegable.

Education otherwise than at school

13. If the council decides school or college is not appropriate for the child or young person, the council can arrange for any special educational provision which the child or young person requires to be delivered somewhere other than in a school, college or early years setting. This is often known as ‘education otherwise than at school’ (EOTAS). The council would then be responsible for continuing to secure and fund that provision. (Children and Families Act 2014, section 61)
14. For a child or young person with an EHC plan, where the council specifies ‘education otherwise than at school’ in the Plan, the council must ensure the SEP is delivered. This could include therapies which are classed as educational provision, such as speech and language therapy.
15. If a child or young person will not be attending a school or institution at all, their EHC plan should describe their SEP in section F and section I should be left blank. (Derbyshire CC v EM and DM (SEN) [2019] UKUT 240 (AAC))

Appeal rights

16. There is a right of appeal to the SEND Tribunal against a decision not to assess, issue or amend an EHC Plan or about the content of the final EHC Plan. Parents must consider mediation before deciding to appeal. An appeal right is only engaged once a decision not to assess, issue or amend a plan has been made and sent to the parent or a final EHC Plan has been issued.

Arrangements for reviewing an EHC Plan

17. The procedure for reviewing and amending EHC plans is set out in legislation and government guidance.
18. Within four weeks of a review meeting, a council must notify the child’s parent of its decision to maintain, amend or discontinue the EHC plan. (Section 20(10) Special Educational Needs and Disability Regulations 2014 and SEN Code paragraph 9.176)
19. Where a council proposes to amend an EHC plan, the law says it must send the child’s parent or the young person a copy of the existing (non-amended) plan and an accompanying notice providing details of the proposed amendments, including copies of any evidence to support the proposed changes. (Section 22(2) Special Educational Needs and Disability Regulations 2014 and SEN Code paragraph 9.194)
20. The Special Educational Needs and Disability Code states if a council decides to amend the plan, it should start the process of amendment “without delay”. (SEN Code paragraph 9.176)
21. Following comments from the child’s parent or the young person, if the council decides to continue to make amendments, it must issue the amended EHC plan as soon as practicable and within eight weeks of the date it sent the EHC plan and proposed amendments to the parents. (Section 22(3) SEND Regulations 2014 and SEN Code paragraph 9.196)
22. Parents have a right of appeal to the SEND Tribunal if they disagree with the special educational provision or the school named in their child’s EHC plan. The right of appeal is only engaged when the final amended plan is issued.

Alternative provision

23. Councils must arrange suitable education at school or elsewhere for pupils who are out of school because of exclusion, illness or for other reasons, if they would not receive suitable education without such arrangements. [The provision generally should be full-time unless it is not in the child’s interests.] (Education Act 1996, section 19). We refer to this as section 19 or alternative education provision.
24. This applies to all children of compulsory school age living in the local council area, whether or not they are on the roll of a school. (Statutory guidance ‘Alternative Provision’ January 2013)
25. The courts have considered the circumstances where the section 19 duty applies. Caselaw has established that a council will have a duty to provide alternative education under section 19 if there is no suitable education available to the child which is “reasonably practicable” for the child to access. The “acid test” is whether educational provision the council has offered is “available and accessible to the child”. (R (on the application of DS) v Wolverhampton City Council 2017)

What happened

26. Miss X’s child, Z, has special educational needs (SEN) connected with several conditions, including ME/CFS (myalgic encephalomyelitis, also called chronic fatigue syndrome) and anxiety. Z has an Education, Health and Care Plan (EHC Plan).
27. In September 2021, Z started Year 10. Z had been unable to attend school due to illness for several years. Z was receiving some provision arranged by the Council with Alternative Provision Provider One.
28. The Council held Z’s annual review meeting. The Council agreed to carry out certain actions following the meeting.
29. Alternative Provision Provider One chased the SEN Provision Officer for an update on the annual review actions and draft amended Plan. The SEN Provision Officer replied to say she was experiencing an extremely high number of calls and emails, but was working to move Z’s Plan forward as quickly as possible.
30. In October, the Council sent Miss X its decision letter saying it had decided to amend Z’s Plan.
31. In early December, Miss X complained to the Council that it had failed to complete the actions agreed at the annual review meeting. She said:

• the Council arranged Educational Psychologist (EP) had failed to complete an adequate assessment of Z’s needs to inform the amended Plan;
• the Council had failed to arrange the SEN Specialist Services (SENSS) assessment to inform the amended Plan;
• Z’s SEND Caseworker at the Council had failed to consider providing Z with a wheelchair and chase CAHMS to arrange support;
• Z’s SEND Caseworker had failed to arrange a specialised programme to support Z’s reading and vision and opportunities for Z to work on social skills, music therapy and a Personal Budget; and,
• failed to issue an updated amended final Plan.

32. Miss X said Z felt let down and the situation had significantly affected her mental health. Z was still not attending school and was struggling to engage with the alternative provision. She said Z was caused uncertainty and distress about what placement she would attend as the Council had failed to find a suitable one.
33. In mid-December, a Senior Officer in the Council’s SEND Team met with Alternative Provision Provider One. The Senior Officer agreed to certain actions.
34. In early January 2022, the Council sent Miss X its stage one complaint response. It decided to uphold Miss X’s complaint. The Council said it had asked a Senior EP to complete a reassessment of Z’s needs.
35. At the end of January, a Senior EP visited Z.
36. In early February, CAMHS sent Miss X a report following an assessment of Z, which confirmed Z had autism spectrum condition (ASC).
37. The next day, after Miss X told the Ombudsman she was unhappy with the Council’s stage one response, the Council sent Miss X its final complaint response. It upheld Miss X’s complaint. It said the SENSS assessment would take place by the end of February and it needed to see the EP report before deciding on Miss X’s request for music therapy and art therapy.
38. The Senior EP caried out a second visit to Z as part of the reassessment. The EP report was shared with the Council’s SEND Team.
39. In mid-March, a Senior Officer in the Council’s SEND Team arranged a meeting with Z, Miss X, and Alternative Provision Provider One. The Senior Officer emailed Miss X to confirm the Council’s SEND Team would send a draft amended Plan to Miss X in early April.
40. In early May, Miss X chased the Council to finalise Z’s Plan.
41. Alternative Provision Provider One contacted the Council to ask about exploring options that would allow a slow return to a school environment for Z. They said Z had said recently she was considering how a gradual return to education would help her meet people and have educational opportunities again.
42. In mid-May, Z’s SEN Caseworker emailed Miss X a copy of the draft amended EHC Plan. The Caseworker sent Miss X a copy of Z’s SENSS assessment by a Specialist Teacher from March.
43. Later in May, Miss X sent the Council her comments and requested amendments to the draft Plan.
44. In mid-June, a Senior Officer in the SEND Team contacted Miss X to arrange a follow up meeting to make any further amendments to the Plan.
45. The follow up meeting was scheduled for the end of June. But, this did not go ahead as Miss X asked the Council to rearrange this for when the Senior Officer in the SEND Team was able to attend.
46. On 20 July, the Council held the follow up meeting with Miss X. It said the Council agreed to education otherwise than at school (EOTAS).
47. On 24 October, the Council issued a final amended EHC Plan.

Analysis – was there fault by the Council causing injustice?

Annual review process

48. Miss X complains the Council failed to complete Z’s 2021/22 annual review and issue an amended EHC Plan.
49. In the Council’s stage one and stage two complaint responses (from January and February 2022), it accepted the Council had failed to complete the annual review within the statutory timescales. This is fault (part a of the complaint).
50. The Council told us that it aimed to complete Z’s annual review by February 2022. But, it failed to issue the final amended Plan until 24 October, over seven months later. This is fault. Z missed out on an updated Plan that reflected her needs and the provision the Council should arrange for her.
51. Miss X was denied appeal rights to the SEND Tribunal. The Council notified Miss X of her right to appeal its decision to amend the Plan. But, as explained above, this is not correct. The right of appeal following a decision by the Council to amend the Plan is only engaged when the final amended Plan is issued.
52. In my view, much of the delays in the Council completing the annual review process were caused by the following:
53. The Council must obtain advice and information from certain people and professionals and circulate this to those invited to the annual review meeting two weeks before. This should have included advice and information from a Council Social Care officer and an Education Officer as well as a health care professional. Based on the evidence I have seen, the Council failed to obtain and circulate this advice and information ahead of the meeting. The record of the annual review meeting shows the Council failed to invite a Social Care officer and ask them to contribute to the annual review. This is fault. In my view, the Council’s failure to obtain this advice and information right at the start of the annual review contributed to delays in the process and the Council’s decision-making as it was missing key information to assist with this.
54. In its complaint responses, the Council accepted it had failed to complete the actions it had agreed to during the annual review meeting. This is fault. There were either significant delays in the Council completing these actions or certain actions remain outstanding. This also applies to actions agreed by a Senior Officer in the Council’s SEND Team, when she met with Alternative Provision Provider One in December 2021. Having reviewed the documents available to me, including the final Plan from October 2022, I find this applies to the following agreed actions:

• the Council agreed to arrange an EP assessment and SENSS assessment by the week after the annual review meeting. But, there were issues with the first EP report because the visits by the EP were not completed sufficiently. This caused delays in the Council arranging a suitable EP report, which meant this was not completed until February 2022. The SENSS assessment by a Specialist Teacher did not take place until February 2022 and the report was shared with Miss X with the draft amended Plan in May. These delays are fault (part b of the complaint).
• the Council’s SEND Team agreed to follow up on the request made by Miss X in August 2021 to provide Z with an electric wheelchair. Council records show Z’s SEN Provision Officer contacted the Council’s Children Who are Disabled Social Care team later in September 2021. The SEN Provision Officer asked how Z could borrow or hire an electric wheelchair. The Officer said Z had access to a manual wheelchair, but Miss X was unable to push this any distance when Z became fatigued due to the impact of Miss X’s health conditions. Based on the evidence I have seen, the Council failed to make a decision on whether or not Z could have access to an electric wheelchair. This is fault. This caused Z and Miss X uncertainty about what support, if any, the Council could provide. In the end, Miss X arranged this with Z’s paediatrician.
• the Council’s SEND Team would follow up with its social care team to look into social care provision and allocating a family support worker. In its stage two complaint response, the Council said this had not been completed. It said a Senior SEN Family Worker would contact Miss X to talk through the family assessment of need process and aim to complete the assessment in the first week of March 2022. It said this assessment would look at support and short breaks for Miss X and support for Z. It signposted Miss X to its carers support service. But, the Council told me the family assessment did not take place and it has not carried out a carer’s assessment for Miss X. The reason for this was because the family had not been allocated a new SEN Family Worker when their previous one was no longer able to manage their case. This is fault. Miss X and Z have missed out on a timely family assessment of needs and carer’s assessment, which would confirm what social care support, if any, the Council should provide them. Z’s Plan from October says Miss X’s carer’s assessment still has not been carried out and it is my understanding that, at the time of writing, this applies to the family assessment of need too. This is fault.
• the Council’s SEND Team agreed to look into Miss X’s request for a personal budget to cover tuition, music therapy for Z, a specialised programme to support Z’s reading and vision, and a laptop for Z’s school work. But, it took until the issuing of the final Plan in October – over a year later – for the Council to confirm the personal budget it had agreed to, which included funding the specialised reading and vision programme, music technology sessions and English and maths tuition. This delay is fault. I have seen no evidence that a decision was made about the laptop. This is further fault. I have recommended the Council respond to this request now.
• by failing to issue an amended final Plan for Z, the Council left Miss X and Z in limbo. Miss X and Z have been caused significant distress and uncertainty about whether or not the Council would name a placement in Section I and, if so, when Z would be able to start there. The annual review meeting papers show that the Council recommended Z attend a specialist school setting. We would have expected the Council to have followed this up with consultations with possible specialist schools to promptly inform its decision on suitability. But, based on the evidence I have seen, the Council failed to consider this further. Rather, in August 2022, almost a year after the annual review meeting, it decided “education otherwise than at school” had been agreed with Miss X. In my view, there has been significant drift around the Council’s decision on where it considers Z should access her education. This is fault. I find, because of this, Z has missed out starting the 2022/23 academic school year with a clear package of EOTAS that could be promptly put in place. It is likely, given the reasons why Z was out of education and unable to attend school, the Council missed earlier opportunities to consider sooner if EOTAS was suitable for Z.

55. On a final point regarding Z’s annual review, I asked the Council how planning around preparing Z for adulthood had been considered during the annual review as Z was in Year 10 at the time. I asked the Council to include details of whether the Council had considered offering Z an independent advocate.
56. Councils must ensure that EHC plan reviews from Year 9 (age 13-14) include a focus on preparing for adulthood, including possible further education.
57. The Council told me Z was receiving support from Alternative Provision Provider One and it had not offered an independent advocate. Based on the Council’s response and Section D on life skills and preparing for independence in Z’s final Plan, I am not satisfied the Council has sufficiently considered the requirements around planning and preparing for adulthood during Z’s annual review. This is fault. I have, therefore, recommended the Council reports back on how it has ensured Z’s annual review has included a focus on preparing Z for adulthood. In line with paragraphs 1.9, 1.10 and 8.10 of the SEND Code of Practice, this should include information on the Council’s review of the following:

• support identified to prepare Z for higher education and/or employment. This should include: identifying appropriate post-16 pathways that will lead to these outcomes and discussing training options;
• support to prepare for independent living, including exploring what decisions Z wants to take for herself and planning her role in decision making as she becomes older. This should also include discussing where Z wants to live in the future, who she wants to live with and what support she will need. Local housing options, support in finding accommodation, housing benefits and social care support should be explained;
• support in maintaining good health in adult life;
• support in participating in society, including understanding mobility and transport support, and how to find out about social and community activities, and opportunities for engagement in local decision-making; and,
• consider whether Z may require support expressing her views, including whether she may need support from an advocate (who could be a family member or a professional). The Code says the importance of this consideration is linked to the Council supporting children, young people and their families prepare for the change in status under SEN law that occurs once the child reaches the end of compulsory school age.

Communication with Miss X

58. In the Council’s stage two complaint response, it accepted that, between the annual review meeting in September and mid-December 2021, contact with its SEND Team was not effective and it could have done more to keep Miss X updated. This is fault (part c of the complaint). It is my understanding that the fault accepted here was linked with several staff changes, which led to drift in the annual review process, and there was failure to ensure there was an efficient handover of outstanding tasks to Z’s new caseworker.
59. The Council provided Miss X with details of Z’s new SEN caseworker and apologised to Miss X. I find this partially remedies the significant anxiety and distress Miss X was caused because of the communication issues.
60. But, given there were significant failures during the annual review process, particularly in failing to gather the necessary advice and information from social care, combined with a lack of joined up approach between the SEND team and children’s social care team, I have recommended an additional personal remedy around this.

Alternative provision

61. In the Council’s stage one complaint response, it apologised to Miss X for failing to support Z in accessing full-time educational provision. It said Z had not had access to education in a way that she should have done.
62. The Council went to on to say it was providing alternative provision through Alternative Provision Provider One. But, it accepted this could not replace the “full social and academic experience of more formal provision”. In my view, the Council has accepted here that it has failed to arrange a full package of alternative provision that it has assessed as suitable to Z’s age, ability and aptitude, including any special educational needs (part d of the complaint).
63. Rather, based on the evidence I have seen, including the EP report from February 2022, Z received very limited provision through Alternative Provision Provider One:

• Z received between eight and 10 hours of provision with Alternative Provision Provider One each week during the 2021/22 academic year, which focused on supporting and encouraging Z to build positive relationships and get out of the house with reengagement officers. But, having been out of school for so long, Z had fallen behind with learning and was not accessing much in the way of education. As she was in Year 10, Z was at a significant point in her education and was in the first of her GCSE exam years. But, her September 2021 annual review meeting record also showed “[Z] has not had any opportunity to interact with other young people” and the Council had no way of assessing Z’s attainment levels in core subjects, such as maths and English.
• the EHC Plan in place for Z from March 2021 provides details of the special educational provision (SEP) the Council should have arranged for Z. The SEP was largely aimed at supporting and managing Z’s ME/CFS and anxiety needs to support her in accessing education. The SEP that the Council had a duty to arrange included making sure: her education provider taught Z strategies for regulating her emotions and supporting her to build her self-esteem, set goals and help manager her anxiety; her education provider should break down and simplify instructions into smaller steps with regular breaks or changes to teaching styles; and make sure Z had access to resources to help her destress and access calming sensory input (such as music and soft lighting). The Plan said the homebased learning should be provided by an education provider with advice from a Specialist Teacher or Educational Psychologist.
• But, based on the evidence I have seen, the Council failed to consider what SEP, if any, it could arrange for Z and put this in place during the 2021/22 academic year while it finalised Z’s Plan. This is fault.
• Given the above findings of fault, I find the Council failed to have due regard to Z’s right to an education given the lack of educational provision provided during what would have been Z’s first GCSE year. (the First Protocol, Human Rights Act 1998, Article 2).

64. The Council has apologised for the failure to arrange suitable alternative provision for Z. But, in my view, this does not suitably remedy the injustice caused to Z.
65. Throughout the 2021/22 academic year, Z became socially isolated from her peers. As explained above, Miss X provided significant care for Z, but the Council failed to carry out a family assessment of needs or carer’s assessment for Miss X.
66. The Council’s failure to arrange suitable alternative provision, combined with its failure to carry out a family assessment of needs and carer’s assessment, meant Miss X was expected to provide significant care for Z while managing her own significant health conditions. This had a considerable impact on Miss X and Z’s life, including their family life. It is likely this affected Miss X and Z’s personal relationships with each other. I find this meant the Council failed to have due regard to its duties under Article 8 of the Human Rights Act 1998 to respect Miss X and Z’s right to respect for their private and family life. In my view, if the Council had promptly arranged suitable alternative provision for Z, including any SEP, and carried out the two assessments, then it would have been able to decide how it could promote good family and other relationships for Z while she was at home, and support her right to participate in social activities. I have taken this injustice into account when recommending a distress payment for Miss X above our usual range.
67. Where fault has resulted in a loss of educational provision, we normally recommend a remedy payment of between £200 and £600 a month to acknowledge the impact of that loss. The figure is based on the circumstances of each case, to reflect the particular impact on that child. In this case, I have taken into consideration the fact Z was at a key stage of her education and was significantly isolated from her peers, but receiving almost no provision. I, therefore, recommend a payment of £500 per school month for the 2021/22 academic year (after deducting school holidays).

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Agreed action

68. Within four weeks of my final decision, the Council has agreed to:
1. apologise in writing to Z for the fault causing injustice;
2. apologise in writing to Miss X for the fault causing injustice;
3. make Miss X a payment of £500 for each school month between September 2021 and 24 October 2022 when the Council provided some reengagement provision, but no formal education and SEP for Z. This comes to a total of £5,375, which is to be used for Z’s educational benefit;
4. make Miss X a payment of £400 to recognise the significant stress and distress caused, including the particular impact the fault had on Z and Miss X’s personal and family relationships, and the missed opportunity to have a prompt family assessment of needs and carer’s assessment;
5. make Miss X a payment of £150 to recognise the significant time and trouble she was put to chasing the Council to complete the annual review and provide a clear package of EOTAS, including with a personal budget around this;
6. respond to Miss X’s request to provide Z with a laptop. If the Council refuses this decision, it should provide Miss X with clear reasons and, if applicable, details of any review rights;
7. obtain social care advice, as required under the statutory annual review process. The Council should also carry out the family assessment of needs and offer Miss X a carer’s assessment. The Council should report back on the outcome of these assessments and provide copies of the assessments and the social care advice. The Council should consider whether Z’s EHC Plan requires updating following these assessments and advice. If so, the Council should provide Miss X with an amended final Plan with fresh SEND Tribunal appeal rights within this timescale;
8. report back on how the Council has considered and discussed planning for adulthood with Z and any advice/information given. As part of this, the Council should consider independent advocacy options for Z and, if considered appropriate, offer these to Z. The Council should include a record of its decision-making on advocacy options in Z’s case file for future reference; and,
9. consider how it will improve communications with Miss X going ahead, including making sure there are clear links between Z’s SEND Caseworker and children’s social care team.
69. Within three months of my final decision, the Council has also agreed to:
• review any template letters concerning decisions/notices to amend an EHC Plan following an annual review meeting to ensure it is clear that information on the SEND Tribunal right of appeal must be provided with the final amended EHC plan. This is because this right of appeal is only engaged when the final amended Plan is issued, not before. The Council should circulate any amended template letters to relevant staff with a reminder on this;
• circulate a reminder to staff detailing the people and professionals that the Council must obtain advice and information from during the annual review. This should include advice and information from a Council Social Care officer, an Education Officer and a health care professional. The reminder should flag that the Council should circulate this advice and information to those invited to the annual review meeting two weeks before the meeting;
• circulate a reminder to relevant staff that EHC plan reviews from Year 9 (age 13-14) must include a focus on preparing for adulthood, including possible further education. These reviews should result in clear outcomes which are ambitious and prepare young people for adulthood. This reminder should include details of the areas of support the Council should consider based on paragraphs 1.9, 1.10 and 8.10 of the SEND Code of Practice (see paragraph 57 above); and,
• ask a Senior Officer in its SEN team and its children’s social care team to review the decision statement and share any identified points of learning with their teams.
70. The Council should provide us with evidence it has complied with the above actions.

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Final decision

71. I have completed my investigation.
72. The Council has accepted it was at fault in relation to parts a to d of the complaint. But, I do not find the Council has suitably remedied the injustice caused by the fault. The above recommendations are suitable ways for the Council to fully remedy the injustice caused to Z and Miss X, which the Council has agreed to.

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Investigator's decision on behalf of the Ombudsman