Summary: The Council was at fault, because it did not give due consideration to its enforcement powers when dealing with a child who was refusing to attend school. The Council has agreed to address this fault by providing guidance to officers on the importance of clear decision-making and the robust implementation of the Council’s powers, where appropriate. The Council was also at fault for a delay in making a formal decision to amend the child’s education, health and care plan, but this did not cause an injustice. The Council was not at fault for failing to arrange mediation, as this was not its responsibility.

The complaint

1. Mr W complains the Council has failed to discharge its duties with respect to the education of his son, M. Mr W says that, as a consequence of this, M has received very little secondary education.

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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 investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
4. We investigate complaints about councils and certain other bodies. We cannot investigate the actions of bodies such as the NHS. (Local Government Act 1974, sections 25 and 34A, as amended)
5. We cannot investigate most complaints about what happens in schools. (Local Government Act 1974, Schedule 5, paragraph 5(2), as amended)
6. The First-tier Tribunal (Special Educational Needs and Disability) considers appeals against council decisions regarding special educational needs. We refer to it as the SEND Tribunal in this decision statement. The law says we cannot normally investigate a complaint when someone can appeal to a tribunal about the same matter. (Local Government Act 1974, section 26(6)(a), as amended)

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How I considered this complaint

7. I reviewed the Council’s correspondence with Mr W, along with various other bodies relevant to this complaint, such as schools and the NHS.
8. I also shared a draft copy of this decision with each party for their comments.

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What I found

9. Mr W’s complaint to the Council covers events in M’s education going back to 2018. However, the law says a person should approach us within 12 months of becoming aware of the issue they wish to complain about. This is called the ‘permitted period’. Mr W complained to the Ombudsman in November 2022, meaning any events prior to November 2021 fall outside the permitted period.
10. The law does permit us some flexibility in the application of this rule, but in order to accept a late complaint for investigation, we must first be satisfied there are good reasons the complainant did not approach us sooner. We must also be satisfied it is still possible to conduct a meaningful and robust investigation.
11. In this case, I note Mr W has been in constant and detailed contact with the Council during the course of events here, and has also made proactive visits to schools suggested by the Council as possible placements for M, writing reports on his findings. This being so, I am not persuaded it was unreasonable to expect Mr W to have approached the Ombudsman sooner than November 2022, if he wished to complain about earlier events.
12. For this reason, I will not disapply the late complaint rule here, and consequently my investigation will only cover the period from November 2021 onwards, although I may refer to earlier events where necessary for context.
13. The following chronology is to provide an overview of the key events relevant to this complaint. It is not intended to provide a detailed account of everything which happened.
14. M has been diagnosed with a range of conditions, which include developmental and learning difficulties. He was subject to a statement of educational need from a young age, which the Council converted to an education, health and care (EHC) plan after the introduction of the Children and Families Act 2014.
15. M attended a mainstream school through most of his primary education, before moving to a specialist inclusion centre for the final few months. Around this time the Council named on M’s EHC plan the specialist provision centre of a secondary school (which I will refer to as School 1), for when he started secondary education in September 2019. Mr W appealed to the SEND Tribunal about this decision, which led to the EHC plan being amended for M to attend the specialist provision of a different school (School 2).
16. M attended School 2 for Year 7, and then transferred to another, mainstream school (School 3) in September 2020 after a parental request. However, M’s attendance at this school was inconsistent, and by November 2021, he was on a reduced timetable there.
17. In November 2021 the Council enquired with School 3 about its plan to return M to full attendance. The school responded that M was expected to return full-time in January 2022. In the meantime the Council sought to arrange some part-time tutoring for M. Mr W later emailed the Council expressing a range of concerns about how the school was working with M, but said he felt it was the right placement for him.
18. A meeting between the school, Council and Mr W was arranged for December 2021, but was cancelled by the school. In February 2022, it contacted the Council and sought to rearrange the meeting.
19. Around this time Mr W emailed the Council to say M was no longer attending school due to his anxiety. He asked the Council to meet him during the upcoming half-term to discuss possible alternative provision for M, but the case officer responded to say they were on leave at this time. The officer also explained the school would need to be involved in any discussion about M’s attendance.
20. The annual review of M’s EHC plan took place in March, at a meeting between M and his parents, the Council, and members of school staff. It was agreed M would return to school, and a further meeting was scheduled for the end of the year to discuss whether School 3 was the right place for him. In the meantime the Council arranged support for M from an educational psychologist (EP) for six weeks.
21. However, a week later the school contacted the Council to say M had not attended at all since the meeting. The school requested a change of placement for him. It also reported to the Council that a practitioner from the Children and Adolescent Mental Health Service (CAMHS) had said it was not M’s mental health which was a barrier to his attendance, but his focus on past experiences and a lack of sustained engagement. The practitioner had questioned whether there was a role for CAMHS in M’s case.
22. In April Mr W told the Council he would not return M back to School 3, because of “errors in judgement and poor professional practice”. He asked the Council for a meeting to discuss alternative provision.
23. The Council replied to offer a meeting in May, but explained M would remain on roll at School 3 until a new placement was secured. It explained to Mr W it could not formally decide a placement for M at a meeting, as it would need to be referred to the Council’s decision-making panel, but made a number of suggestions for possible placements, including Schools 1 and 2. The Council also made a referral to the Early Help service to request support for M while it arranged a new placement.
24. Mr W wrote back to the Council to say he intended to visit the proposed schools. The meeting was then postponed because he had been unable to do so yet, but the Council said it needed to know parental preferences soon, or it would be forced to proceed with making arrangements as M was out of school.
25. In May the Early Help service replied to the referral to say it considered CAMHS was more appropriate to support M, to assist him with coping strategies. The Council contacted CAMHS, which repeated its view that M did not have serious anxiety problems. It said:

“He has difficulties accepting when things are not to his expectation and his history of non-school attendance and previous difficulties with school placements feed into this as he reflects and compares things and focuses very much on the negative.”

26. Mr W contacted the Council offering a detailed critique of School 1 and why he did not think it suitable for M. He said he was now intending to visit School 2, and another school with specialist provision, School 4. A few days later Mr W confirmed he had visited School 4, which he thought was appropriate for M.
27. The Council replied to Mr W to say it would take School 4 as his preference. It also told him it would need written medical confirmation that M could not attend school for health reasons, such as anxiety, for it to consult with School 2, as this was part of its admission criteria.
28. In June the Council sent consultations to Schools 1 and 4. School 1 responded almost immediately to confirm it could meet M’s needs, and offered a placement to begin in September.
29. Mr W submitted a complaint the Council had not yet issued a decision on the annual review from March. He said he felt M’s EHC plan was “not fit for purpose”. The Council contacted School 3 to enquire whether it remained satisfied with the report on the annual review, which it replied to confirm it was. The Council then replied to Mr W’s complaint.
30. The Council wrote to CAMHS, the Early Help service and an EP for their advice in changing M’s school placement, and for their comments on Mr W’s views about his needs, and requested their responses by early July. The Council then wrote to Mr W to confirm it intended to amend M’s EHC plan.
31. In July the Council received responses from CAMHS and the EP for consideration in amending M’s EHC plan. School 3 responded to the Council’s consultation to say continued placement there for M was not appropriate. School 4 responded to say a placement for M might be suitable in the ‘longer term’, but said its specialist provision was currently at capacity and could not accept any more pupils, it would not be able to provide 1:1 support to M for several months, and that its existing pupils had already started Key Stage 4 work, which meant M would not be able to take part in some lessons.
32. In August the Council issued a final amended EHC plan, naming School 1 as M’s placement. In a covering letter to Mr W, it explained it could not consult with School 2 because it had no written evidence M could not attend school for health reasons, and could not name School 4 because it was at capacity, along with the other concerns it had raised. The Council said School 1 had confirmed it could meet M’s needs and was the most suitable available placement for him.
33. Mr W replied to agree the EHC plan was improved, but said he would not be sending M to School 1 because he did not consider relevant staff there to be qualified for their role. Mr W also complained he could not visit School 2.
34. In response, the Council explained Mr W had the right of appeal against the named placement and this was the appropriate way for him to challenge it. It also said it was open to Mr W to visit School 2 if he wished, but reiterated the evidence it needed to meet the school’s admission criteria.
35. After further correspondence reiterating his views, that he would not send M to School 1, and that he intended to visit School 2, Mr W submitted a formal complaint to the Council, covering what he considered to be five years of failings by the Council with respect to M’s education.
36. In September, School 2 emailed Mr W to confirm it was happy for him to visit, but warned it was at capacity and had a waiting list. Meanwhile School 1 put M on its roll.
37. The Council sent a formal consultation to School 2 at Mr W’s request after he had visited. After further correspondence with Mr W, the Council said it had not received a request for mediation, as Mr W had said, and sent him an information sheet about this.
38. School 2 then replied to the Council’s consultation to agree it was suitable for M, and confirmed it had added him to its waiting list.
39. The Council responded to Mr W’s complaint of August. It confirmed M was now on the waiting list for School 2, and in response to Mr W’s various points of complaint, it said:

• M had had a named school placement at all times since 2018;
• evidence supported the conclusion M had “mild” learning difficulties, and not moderate ones as Mr W believed;
• M had received regular reviews from the Council’s EP team, most recently in March;
• it considered it appropriate to refer M to Early Help because of his attendance problems;
• the Council’s SEN team had been in frequent contact with Mr W and M’s mother and had sought to “work professionally” to resolve their concerns;
• there was an ongoing parental responsibility to ensure M attended school;
• it did not agree School 1 could not meet M’s needs; and
• it would not reallocate M’s case to other members of staff.

40. Mr W responded disagreeing with the Council’s comments.
41. In October, the Council wrote to School 2 to enquire whether it could offer M a place with its reintegration and tuition service, while he waited for a full placement.
42. School 1 wrote to the Council to say that, unless other provision was being sought for M, it should proceed to attendance enforcement action and make a safeguarding referral. The Council replied to confirm it was seeking tuition from School 2, and that it did not consider a safeguarding referral necessary because the Early Help service had expressed no concerns about M.
43. In November the Council responded to Mr W’s stage 2 complaint. It said:

• M had what the Council considered to be a suitable school placement;
• it had not agreed to remove an EP report from 2018 from M’s file, the contents of which Mr W disputed;
• M was on the waiting list for School 2;
• School 2 had offered M online tuition and support while he was on the waiting list;
• there was a new Neurodiversity Team at the Council and provided its contact details;
• it would agree to further EP input once M started his new school; and
• that Mr W could now approach the Ombudsman with his complaint.

44. In December, the Council also discussed M’s case with the Special Educational Needs and Disabilities Information Advice and Support Service (SENDIASS). It confirmed Mr W would not accept M’s placement at School 1, and nor would he accept the online tuition package offered by School 2, as he instead wanted a bespoke package.
45. In January 2023 School 2 wrote to the Council to confirm Mr W would not permit mentors from the reintegration and tuition service to visit M at home, and nor would he access any online learning. After further correspondence from Mr W in February and March, and an attempt by him to visit the Council’s SEN team at its office, the Council wrote to Mr W to confirm M could start at School 2 in April.

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Legislative background

Education, health and care plans

46. A child with special educational needs may have an 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 SEND Tribunal can do this.
47. The procedure for reviewing and amending EHC plans is set out in legislation and government guidance.

Annual reviews

48. 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)
49. 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)
50. 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)
51. 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

52. Under section 19 of the Education Act 1996 councils have a duty to make arrangements for the provision of suitable education, at school or otherwise, for children who, because of illness or other reasons, may not receive suitable education unless such arrangements are made for them.
53. Councils must “make arrangements for the provision of suitable education at school or otherwise than at school for those children of compulsory school age who, by reason of illness, exclusion from school or otherwise, may not for any period receive suitable education unless such arrangements are made for them.” (Education Act 1996, section 19(1))
54. The Courts have found that it is a judgement for the council to decide whether a child’s health needs prevent them from attending school and to decide what weight to give medical evidence. (R (on the application of D (by his mother and litigation friend)) v A local authority [2020])

Attendance

55. The Education Act 1996 places a duty on parents to ensure their children of compulsory school age, receive a suitable full-time education. Failure to meet this duty is an offence. Councils have the power to prosecute parents who fail to ensure their child’s regular attendance at school. If the court finds a parent guilty of an offence they can receive a fine or imprisonment of up to three months.

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Analysis

56. Mr W’s complaints to the Council are extensive and raise numerous points about what he sees as failings by the Council, and M’s various schools, over a period years. I am aware Mr W has also now made a complaint in a similar vein to CAMHS.
57. I have already noted we are limited by law in the time period we can investigate. The law also prevents us from investigating complaints about the internal management of schools, and about CAMHS, which as part of the NHS falls under the jurisdiction of the Parliamentary and Health Service Ombudsman (PHSO).
58. The law also says we should not normally investigate complaints about matters where the complainant had a right of appeal to a court or tribunal. Disputes about the content of EHC plans, including the named placement, carry a right of appeal to the SEND Tribunal, and so this restriction applies here.
59. Again, the law permits us the discretion to disapply this restriction, where we feel it would be unreasonable for someone to use their appeal right. However, for the same reasons I discussed previously, I do not consider there is any evidence Mr W could not reasonable be expected to have used his appeal right. I will not, therefore, consider Mr W’s complaint about the content of M’s EHC plan.
60. I should note this restriction does not apply to complaints about problems with the EHC plan procedure, such as a delay in issuing a plan. This is because the Tribunal does not have the power to consider such matters, and they instead fall into our jurisdiction.
61. More generally, as a publicly funded body we must be careful how we use our resources. We conduct proportionate investigations; completing them when we consider we have enough evidence to make a sound decision. This means we do not try to answer every single question a complainant may have about what the organisation did, but instead focus on the issue(s) which have the potential to cause significant injustice. The appropriateness of this has been agreed by the courts.
62. This being so, I have limited my investigation to determining whether the Council properly considered and discharged its duties, arising from M’s absence from school during the period November 2021 to date. I will also consider two additional points Mr W has raised, about a delay in issuing M’s EHC plan, and about the arrangement of mediation.
63. For ease of understanding, I will address each of these points in turn.

M’s absence from school

64. Where a child of compulsory age is not attending school, there are broadly speaking two ways the local authority can approach the matter. If there is a legitimate reason for the child not to attend school, such as serious health issues, then the authority has a duty to make alternative provision – such as tutoring – for them, and it must do so as soon as it becomes clear the absence will be for 15 days or longer. We refer to this as councils’ ‘s19 duty’.
65. The alternative provision may be a short-term arrangement, until the child’s health improves enough to allow them to return to normal schooling, or a longer-term arrangement, if the prospects of improvement are less encouraging.
66. Alternatively, if there does not appear to be a compelling, legitimate reason for the child not to be attending school, the authority should consider treating it as an attendance matter (‘truancy’), for which it has powers of enforcement. This can include prosecuting the child’s parents or legal guardians.
67. In any particular case, it is a matter of professional judgement for the relevant council to decide which approach is most appropriate. However, we would expect to see the council clearly making and recording an unambiguous decision about it. And in this case, I am concerned the Council did not do this.
68. My attention is drawn, first, to the period where M stopped attending School 3 in March/April 2022. It had been agreed at the recent annual review that M would start attending school full-time again, with support, and CAMHS had provided a clear assessment of M that he did not have medical reasons preventing his attendance.
69. On the face of it therefore, it could be expected the Council would treat this an enforcement matter. However, if the Council had decided to treat this as a legitimate absence, it should have immediately begun arranging alternative provision, because it seems clear M would be out of school for at least 15 days (and this is something Mr W himself raised).
70. But it did neither of these things – instead it simply started discussing possible new placements for M. I do note the Council reminded Mr W that M would remain on roll at School 3 in the meantime, but beyond this, it took no action to enforce his attendance. It also did nothing to arrange alternative provision for him while looking for a new school.
71. A similar criticism can be made when the Council named School 1 as M’s new placement on his reviewed EHC plan. The expectation was that M would start there in September, but Mr W did not accept this and flatly refused to take M to the school. The Council correctly advised Mr W he should appeal against the placement decision if he did not agree with it, but (and despite the school itself urging this course of action) it did not proceed to enforce M’s attendance. Instead it amended the EHC plan yet again to name School 2.
72. The Council was aware School 2 could not immediately offer M a place, and I note it then began making arrangements for M to receive alternative provision, via School 2 itself, for the interim period. It could be said, therefore, the Council had accepted a s19 duty at this point; but if so I would expect to see it clearly recorded it considered M was unable to attend School 1 for medical reasons. In fact the opposite is true, as the Council continued to make clear it considered School 1 suitable for M, pointing again to the CAMHS assessment of his anxiety.
73. And I should note the fact M was waiting for his place at School 2 did not mean he should not have been attending School 1 in the meantime, if this was suitable for him, as the Council believed. Therefore, even accepting the upcoming change of placement, I would expect to see the Council making a robust decision what to do about M’s continued absence from school.
74. On balance, therefore, I consider the Council was at fault because it did not give due consideration to its enforcement powers here. It insisted the placements it had named for M were suitable for him, a position which the evidence from CAMHS strongly supported, and yet it made no meaningful effort to enforce his attendance.
75. Unfortunately I do not consider it possible to define an injustice from this. Given the possibility it could have led to his prosecution if the Council had acted more decisively, I do not consider Mr W himself can be said to have suffered an injustice from its failure to do so.
76. It could be said that more decisive action by the Council would have led to M attending school, and that, therefore, he has suffered an injustice through missed education. But it is far from certain this would have been the outcome, even if the Council had decided to enforce it, and so I am not satisfied it would be appropriate to make this finding.
77. Rather, the injustice to M here is simply the uncertainty about what may have happened. But, while we commonly recommend a remedy for uncertainty, I am still not satisfied it is possible to properly define it in this case, to the point where I can suggest a meaningful remedy for M. And I am conscious he is shortly due to start at School 2, which will hopefully resolve the problem of his absence.
78. I will therefore not recommend a remedy here. However, I consider the Council should take steps to ensure relevant staff understand and are confident in applying the powers and duties they have in situations such as this one. I will explore this in more detail in the next section.

Delay in issuing M’s EHC plan

79. After an annual review, a council must decide whether to maintain, amend or discontinue an EHC plan. Whatever its decision, it must inform relevant parties, including parents, of this within four weeks.
80. If the council decides to amend the EHC plan, including by changing the named placement, it must then issue a draft amended plan. There is no timescale set out for this step in the SEN Code of Practice, but once it has issued the draft amended plan, the council then has another eight weeks in which to finalise it.
81. In this case, M’s annual review was held on 22 March 2022. This meant the Council had until 19 April to decide whether to amend it, and inform Mr W and other relevant parties; however it did not do so until 22 June, more than 13 weeks later. The Council then issued the final EHC plan on 12 August, which was within the eight-week deadline for this phase, but the delay in issuing the decision to amend is fault.
82. This said, I am conscious the Council was not inactive during this period, and was in the process of consulting with the new placements it was proposing for M, a process which Mr W was heavily involved in. Even though the Council had not formally issued its decision to amend, therefore, it was clear this was its intent.
83. I understand Mr W considered the contents of M’s existing EHC plan to be inaccurate and out-of-date. As I explained before, I cannot consider this point myself, because it is a matter for the Tribunal. However, whatever the facts here, it is difficult to see what difference this could have made at that time, given M was not receiving the provision set out in the plan anyway due to his absence from school.
84. Taking this together, although the Council was at fault for the delay in issuing its decision to amend M’s EHC plan, I am not persuaded this caused any significant injustice.

Mediation

85. As I understand it, Mr W is referring here to the mediation which the Tribunal expects parents and councils to attempt, before a dispute is formally taken to appeal.
86. When the Council issued the final EHC plan, it included a factsheet which says:

“Parents and young people who wish to make an appeal to the Tribunal may do so only after they have contacted an independent mediation adviser and discussed whether mediation might be a suitable way of resolving the disagreement. Parents or young people have a right to go to mediation and they must contact a mediation adviser before registering an appeal with the Tribunal. After discussing mediation with the provider, parents and young people will be issued with a certificate which must be provided to the First Tier Tribunal before any appeal can be made.”

87. It also provided a leaflet giving the contact details for the mediation provider the Council works with.
88. About a month later, Mr W wrote to the Council saying he wished to appeal against the Council’s placement and decision and was “await[ing] mediation”. The Council replied the same day to say it had not received a request for mediation from its provider, and attached another copy of its factsheet.
89. It appears Mr W was under the impression it was for the Council to action his request for mediation, but the factsheet makes clear it was for Mr W to do this himself by contacting the mediation provider. It may have been helpful for the Council to have spelled this out more explicitly to Mr W, once it was clear he had misunderstood the process, but on balance I am satisfied the error here was Mr W’s, not the Council’s, and I find no fault on this point.

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Conclusions

90. I find fault by the Council, because it did not give proper consideration to using its enforcement powers in the face of M’s continued refusal to attend his named educational placements. Although the Council could have alternatively accepted its s19 duty was engaged, and make alternative provision for M, the evidence shows it did not consider his absence was because he was medically unable to attend school.
91. The effect of this fault was to cause uncertainty for M, but for the reasons I have given I do not consider it appropriate to recommend a remedy for this.
92. However, as I have said, I consider the Council should take steps to ensure relevant staff understand and are confident in applying the powers and duties they have.
93. I therefore consider the Council should circulate guidance to relevant staff to highlight the fault I have identified in this case, the importance of making a clear decision at the right point, and of acting decisively once they have made that decision. I make a recommendation to this effect.
94. On this particular point, in a focus report we published in July 2022 (Out of school, out of sight?), we issued guidance on how we expect councils to fulfil their responsibilities to provide education for children who, for whatever reason, do not attend school full-time.
95. We made six recommendations. Councils should:

• consider the individual circumstances of each case and be aware that a council may need to act whatever the reason for absence (except for minor issues that schools deal with on a day-to-day basis) – even when a child is on a school roll;
• consult all the professionals involved in a child's education and welfare, taking account of the evidence when making decisions;
• choose (based on all the evidence) whether to require attendance at school or provide the child with suitable alternative provision:
• keep all cases of part-time education under review with a view to increasing it if a child’s capacity to learn increases:
• work with parents and schools to draw up plans to reintegrate children to mainstream education as soon as possible, reviewing and amending plans as necessary:
• put the chosen action into practice without delay to ensure the child is back in education as soon as possible;
• where councils arrange for schools or other bodies to carry out their functions on their behalf, the council remains responsible. Therefore, retain oversight and control to ensure your duties and properly fulfilled.

96. As part of my recommendation, I consider it would be beneficial for the Council to also draw officers’ attention to our published focus report for guidance.
97. The Council was also at fault because it did not issue a timely decision on whether to amend M’s EHC plan after the annual review. However, I do not consider this caused an injustice.
98. The Council was not at fault for failing to arrange mediation, as it had explained adequately that it was for Mr W to contact the mediation provider to initiate this process.

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Agreed action

99. Within one month of the date of my final decision, the Council has agreed to circulate guidance to all relevant staff, explaining the fault we have identified in this case. The guidance will highlight:

• the importance of making a timely decision about which approach to take when a child is absent from school;
• the importance of clearly recording this decision and the reason for it; and
• if they consider the absence should not engage the Council’s section 19 duties, the importance of then properly considering and implementing the Council’s powers of enforcement.

100. The guidance will also draw officers’ attention to our recent focus report on this topic, and ask them to read and consider it, particularly the six recommendations the report makes.
101. The Council should provide us with evidence it has complied with the above actions.

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Final decision

102. I have completed my decision with a finding of fault causing injustice.

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Investigator's decision on behalf of the Ombudsman