A support service commissioned by the Council failed to update its riskassessments and share key information with a service user in the weeksbefore they died. The NHS Trust that jointly provided the service then failed toinclude some key information about the service user's case in its internal review and mademistakes in its submissions to the coroner. The Council has agreed to show that the support service it commissions has sent its risk assessment policy to all its staff, along with the Ombudsman's final decision on this case.The Council has agreed to reiterate to all staff at the support service, the importance of sharing information as part of multi-agency working and updating risk assessments in response to key information such as hospital admissions and updates from family and carers.The Council has agreed to show that it has reminded staff at the support service of the importance of following up promptly on contact which indicates an increased risk to a service user, such as reports from concerned family members.The Council has agreed to demonstrate that the NHS Trust it commissions partly to provide the support service, will show that it has considered how to improve its processes for double checking information sent to coroners, to ensure against mistakes in documentation.The Council has agreed to provide evidence from the NHS Trust - which partly commissions the support service - to show it has changed its policy so that family members and carers are now routinely consulted as part of the Trust's internal reviews of cases where a service user has died.

• Provide guidance to staff to consider any action required under the Council’s statutory duties when it becomes aware of non-attendance at schools, and to record all actions, communication and decision making as part of this consideration.

The Council will provide evidence of the action taken for any outstanding points from its action plan relating to service improvements in the fostering service. If the service improvements are ongoing, the Council should provide an anticipated timescale for completion.

The Council will provide us with an explanation about how it will ensure the same fault does not happen again

The Council will provide relevant staff training in making and recording decision-making and the importance of writing decision letters to ensure they give clear reasons for the decisions made. This will help to ensure it provides detailed reasons to people about the decisions it makes so there is a clear understanding about how the decision was reached.The Council will remind relevant staff of the importance of signposting to the Ombudsman at the end of the appeals procedure. This will help to ensure people know how they can escalate the matter further if they are unhappy.

The Council agreed to review its disabled parking bay policy to ensure it:allows the Council to take into account the accessibility of any existing off-street parking in light of an applicant’s disability; clearly sets out how it will consider any neighbour objections when deciding applications, ensuring any objections are weighed appropriately against other aspects of the application;properly takes into account the Council’s duties under the Equalities Act and Human Right’s Act in all cases; andproperly records its consideration of applications, including what weight it gives to different evidence.The Council agreed to provide training to all staff responsible for deciding parking bay applications on:any changes the Council makes to its policy following its review;the importance of considering and weighing all aspects of an application before making a decision and not applying any blanket rules or approaches to applications; andhow to properly record and explain decisions they make.

The Council will consider the reasons for the delay in implementing the provision set out in the EHC plans and produce an action plan to ensure the issues are not repeated.The Council will consider the reasons for the delay in dealing with the complaint and produce an action plan to ensure the issues are not repeated.

The Council was at fault for failing to have suitable oversight of how it funded a young person's education and in how it decided to reduce the young person's funding. The Council will put the Ombudsman's decision to its family and children's services overview and scrutiny committee. This will allow the committee to consider the impact of poor oversight in this case, which led to the complainant misspending a large sum of money allocated for the education of a young person with special educational needs. The committee will also consider what steps are necessary to prevent the faults the Ombudsman identified from happening again. The Council will send the Ombudsman an action plan setting out the steps it will take as a result of the committee's consideration.