Summary: Mrs A complains about an independent investigation report commissioned by a Council about the care of her son, Mr B. I found fault with some aspects of the investigation in relation to communication issues between the family and Mr B’s carers. The Council have agreed to apologise to Mrs A for the uncertainty caused by this fault.

The complaint

1. Mrs A is unhappy with the independent report commissioned by Cambridgeshire County Council into her complaint about her son, Mr B’s care. Mr B’s care is jointly funded by the Council and Cambridgeshire and Peterborough NHS Foundation Trust (the Trust) through the Learning Disability Partnership (LDP). Mrs A has said the report:

• did not address the complaints;
• did not seek evidence from Mr B’s GP, nurse, placement providers and other professionals;
• omitted evidence; and
• submitted unproven evidence and hearsay.

2. Mrs A has said that the result of the investigation is the Council did not alter its approach to her son’s care and his physical and mental health continued to suffer. Mrs A said this process also caused her stress and misery.
3. As an outcome of this complaint Mrs A would like for her son’s capacity to be assessed, his care improved and for his family to be more involved in care planning provision. In addition, Mrs A said the Council should apologise to her and her son.

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The Ombudsmen’s role and powers

4. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
5. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
6. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
7. We will not generally re-investigate the complaints if we find the independent investigator (the Investigator) carried out a robust, evidence-based investigation, that came to a finding on each complaint and where it made appropriate personal and service improvement recommendations (which it has carried out).

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How I considered this complaint

8. In my investigation I have considered evidence from Mrs A, the Council and the Investigator.
9. I offered Mrs A, the Council and the Trust the opportunity to comment on my draft decision statement before I made my final decision.

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What I found

Background

10. Mr B has learning difficulties and lives in a house with live in carers whose purpose is to support him with daily activities such as meal preparation and taking his medication.
11. Mrs A has been unhappy with her son’s care and support for several years and has previously made complaints. These complaints relate to such issues as communication, care provided, lack of capacity assessments and hygiene.
12. This led to the Council, as a means of trying to resolve the complaint, appointing an independent investigator from a firm specialising in these types of investigations.
13. The Investigator sent out their report and made several recommendations relating to sharing information with Mr B’s family and improving communication. Mrs A approached the Ombudsmen as she remained dissatisfied following the investigation.

The investigation did not address the complaints

14. Mrs A has complained that the investigation report did not address all her complaints.

Analysis

15. The Investigator spoke with Mrs A and sent her a scope of the investigation. Mrs A amended this scope to include all her complaints and then signed and sent it back.
16. This means that Mrs A had already agreed that the investigation covered the complaints she raised, and I have not found fault on this aspect of the investigation.

The investigation did not consult the right people

17. Mrs A said the investigation did not take sufficient evidence from her and her daughter who both support Mr B.
18. In addition, Mrs A said the investigation did not take evidence from the many professionals involved in Mr B’s care such as his GP and Community Nurse.
19. Mrs A also said the Investigator did not consult the two placements Mr B attends or the housing association who replaced his bathroom.
20. Furthermore, Mrs A criticised the fact that the Investigator did not interview her son, visit him at home or at any of the placements he attends.
21. Regarding meeting Mr B, the Investigator said they suggested meeting him at home, but Mrs A was reluctant for them to meet Mr B while certain care workers were present. The Investigator said Mrs A suggested meeting with Mr B outside home with her in attendance.
22. The Investigator said they were told that Mr B was growing anxious at the prospect of the meeting. Therefore, the Investigator decided not to meet with him as it would take time to build up trust and they could not achieve that with a one-off visit.
23. Mrs A said that the Investigator only wanted to interview her son in the presence of one of the care workers she had complained about. She said she suggested another venue, but it was rejected by the Investigator. In addition, Mrs A said her son was not anxious meeting the Investigator with Mrs A present but was anxious to do so with the carer present in case he said the wrong thing.
24. The Investigator consulted the care agency manager and workers, Mr B’s social worker, his financial advocate, his sister, assistant directors in adult safeguarding at the Council and the head of LDP.
25. Mrs A has pointed out that these are all members of LDP and the care agency who she has complained about apart from her daughter yet no one else was consulted.

Analysis

26. It may have been useful to interview Mr B, but the Investigator weighed up the benefit of doing so with the effect it may have on him and made the decision not to. I do not criticise this decision as I have not found fault with how they came to it.
27. In relation to the other people consulted as part of the investigation, it was a range of professionals working with Mr B and this was appropriate considering what the complaint was about. The complaint was not about Mr B’s healthcare as such, and so the investigation did not need his clinicians’ input to be robust. It was also fair to speak to Mrs A and her daughter to get their views on the issues.
28. I have not found fault with the list of people the Investigator consulted or with them not including the people Mrs A wanted.

The investigation omitted evidence

29. Mrs A said that she sent various pieces of evidence to the Investigator. These included photos of Mr B’s house to evidence how it was unhygienic as well as photos of him to illustrate his physical decline. In addition, she provided reports from psychologists and complaint correspondence.
30. Mrs A pointed out that none of this evidence was listed in the evidence considered by the Investigator. She felt that this undermined the robustness of the investigation.
31. I enquired of the Investigator if they looked at the evidence Mrs A sent them.
32. The Investigator said many documents which Mrs A sent them were included in the list in the report. The Investigator said that psychologist reports were several years old and in relation to capacity not relevant to the current situation.
33. Regarding the photos, the Investigator said they did look at them, but they believed they were photos from before the bathroom was refitted and so were of limited value as all agreed the bathroom had needed renovated.

Analysis

34. The Investigator listed interviews or statements from the staff members I mentioned above as part of the evidence list along with the case notes of staff which give a daily picture of Mr B’s care.
35. The Investigator also looked at Mr B’s care and support plans to see what his needs were and included evidence from the staff statements on whether these needs were being met.
36. I am satisfied that the Investigator included in their investigation relevant evidence which Mrs A sent them and has given a reasonable explanation as to why the photographic evidence was not deemed relevant.

Submitted unproven evidence and hearsay

37. Mrs A has said that the Investigator relied on unproven evidence and hearsay and this undermined the investigation. It was also upsetting to her, as it included information pertaining to things Mrs A is alleged to have said to support workers which she denied.
38. In addition, Mrs A pointed out that a financial advocate commenting on Mr B’s general health was accepted as evidence when the Investigator themself had earlier said they could not comment on the state of Mr B’s health.

Analysis

39. In their report, the Investigator says that a carer told them that Mrs A had made upsetting comments to another carer. The Investigator did not interview the carer to whom the comments were alleged to have been made.
40. I have found that the Investigator was at fault in not interviewing staff members who had alleged that Mrs A made comments and relying on what was said from a third party, the other carer.
41. They could have also consulted the case records to see if there was a contemporaneous record of this comment but there is no reference to this. Therefore, it was unhelpful to include this without sufficient evidence and it caused upset to Mrs A.
42. I also agree with Mrs A that it was fault to include the views of a financial advocate on Mr B’s health and this meant Mrs A was not confident in the comments relating to the health of Mr B.
43. In addition, in the conclusions of the report there are references to what care staff have told the Investigator that Mrs A has said. There are also references to what Mrs A’s daughter has said carers have said.
44. The Investigator said Mrs A’s daughter’s comments are not supported by documentary evidence. However, they do not reference how the care staff’s views are backed up by documentary evidence. The Investigator created an impression that they placed a higher credibility in the care staff comments rather than those of Mrs A’s daughter. This is not consistent and a fault in the report that led to uncertainty of Mrs A into its conclusions about this aspect of the complaint.
45. Taking these faults into consideration, although they caused distress to Mrs A, I do not find they undermined the credibility of the whole report, rather the conclusions about the relationship between the family and the carers.
46. In relation to including the financial advocate’s opinion on Mr B’s health, this was fault but it does not affect the integrity of the report regarding his health. This is because it was accepted that the Investigator could not make conclusions on this aspect of Mr B’s care.

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Recommendations

47. I have found that the Investigator interviewed the right people in writing their report and did not omit any important pieces of evidence. This means that its conclusions on most of the issues were sufficiently robust.
48. However, it was fault to use a financial advocate’s evidence of Mr B’s health and to include alleged comments made by Mrs A without sufficient evidence. It was also fault to place more credibility on the carers’ comments than those of Mrs A’s daughter’s. These faults have led to uncertainty and distress for Mrs A.
49. Therefore, I recommend that by 17 April 2024 the Council writes to Mrs A acknowledging and apologising for the uncertainty and distress caused to Mrs A by these faults in the investigation.
50. The Council should provide us with evidence it has complied with the above actions.

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Final decision

51. I found fault in relation to some aspects of the investigation commissioned by the Council and made a recommendation in relation to this matter. However, I did not find that the fault compromised the reliability of the whole investigation.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman