Summary: Mr X complained the Council did not properly investigate safeguarding concerns he raised about NHS healthcare he received in 2021 and 2022. There was fault in how the Council considered Mr X’s safeguarding concerns, which caused him avoidable distress. The Council agreed to apologise, properly investigate the concerns, and pay Mr X a financial remedy. It will also review relevant administrative processes and share learning points from our decision with its adult safeguarding staff.

The complaint

1. Mr X complains about how the Council investigated when he raised safeguarding concerns about healthcare he received in 2021 and 2022. He says the Council:
• delayed in completing safeguarding enquiries and telling him the outcome;
• overlooked many of the concerns he raised; and
• failed to provide him with assurances that lessons had been learnt and that he would receive suitable healthcare in future.
2. Mr X says due to his health conditions he regularly needs to visit hospital, and because of the Council’s failure to properly investigate his concerns he does not feel safe doing so in future. He also says the stress caused by the delays in the safeguarding investigation had a harmful impact on his physical and mental health.
3. Mr X wants the Council to:
• apologise for its failings;
• re-open its safeguarding investigation, seek his views, keep him updated, and properly answer each concern he raised; and
• ensure hospital systems have up-to-date notes about his treatment plan to safeguard him for future hospital visits.

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The Ombudsman’s role and powers

4. 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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. 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 or care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
6. 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)
7. The law says we cannot normally investigate a complaint unless we are satisfied the organisation knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the organisation of the complaint and give it an opportunity to investigate and reply. (Local Government Act 1974, section 26(5), section 34(B)6)
8. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
9. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
10. 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

11. I considered:
• information provided by Mr X and discussed the complaint with him;
• documentation and comments from the Counci;
• relevant law and guidance; and
• the Ombudsman’s Guidance on Jurisdiction and Guidance on Remedies.
12. Mr X 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

Safeguarding enquiries

13. Section 42 of the Care Act 2014 says a council must make necessary enquiries if it has reason to think a person:
• may be at risk of abuse or neglect; and
• has needs for care and support which mean they cannot protect themself.
14. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse.
15. Whenever a council receives a complaint or allegation of abuse, it should keep clear and accurate records of the action taken. There should be a clear record of past incidents, concerns, risks, and patterns. (Care and Support Statutory Guidance, Section 14)

The Council’s adult safeguarding investigation policy

16. The Council’s safeguarding adults policy and procedures sets out the process it will follow when responding to safeguarding concerns. This includes the following.
1. Enquiries must be conducted in a timely way. The Council must always have in place clear systems for monitoring and reviewing the progress of enquiry actions to avoid undue delays. At the outset, the person coordinating the enquiry should decide what timescales will be necessary to respond to the concern(s) and clearly record the reasons for this. If at any stage the timescales need to be reviewed, the Council must record the reasons for this, and seek views from the adult who is the subject of the concern.
2. At the end of a section 42 enquiry, the Council must:
1. ensure the enquiry has been thoroughly completed and accurately recorded;
2. review the outcome(s) with the adult before it closes the enquiry, and get direct feedback about their experience of the enquiry; and
3. ensure feedback on the outcomes is passed to the adult, the person or service thought to be the cause of risk, and any other relevant agencies or organisations involved.

What happened

17. Mr X has health conditions which mean he regularly receives medical care and often needs to attend the emergency department in hospital.
18. In 2021 and 2022, Mr X raised three safeguarding concerns with the Council about healthcare he received from the NHS. The Council investigated the concerns under its policy and procedures for safeguarding adults. Mr X also complained separately to the NHS about the healthcare it provided him.
19. In December 2022, Mr X made a complaint to the Council about how it had handled its safeguarding enquiries into his reports. The Council issued its final response to Mr X’s complaint in March 2023, and he then came to the Local Government and Social Care Ombudsman (LGSCO). Mr X also has a complaint with the Parliamentary and Health Service Ombudsman (PHSO), the body responsible for handling complaints about the NHS, which is investigating his NHS complaint about the care itself, separately.

My findings

20. The Ombudsman is not an appeal body, and it is not our role to decide whether neglect or abuse has taken place; that is the Council’s responsibility. We do not take a second look at a decision to decide if it was wrong. We investigate the processes the council followed in making its safeguarding enquiries, to assess whether it made its decision properly. I have considered this for each of the relevant safeguarding concerns, below.

Safeguarding concern raised in September 2021

21. In September 2021, Mr X raised a safeguarding concern with the Council about care he received in hospital in late-August 2021.
22. The law says we cannot investigate events which happened more than 12 months before somebody complained to us, unless we decide there are good reasons to do so. Mr X came to the Ombudsman in March 2023. I decided there are good reasons to investigate what happened from August 2021 onwards, when Mr X was in hospital. This is because the Council took longer than it should have to investigate Mr X’s concerns, which in turn delayed him in coming to the Ombudsman.
23. When Mr X raised the September 2021 concerns, he said the hospital failed to give him his regular prescribed medications, provide pain relief, fully investigate his medical problems, or provide enough discharge information.
24. Six weeks later, the Council decided it should undertake section 42 enquiries. It spoke to Mr X and sought information from the hospital eight weeks later. Over the next nine months, the Council chased the hospital for the requested information five times.
25. After the hospital responded in September 2022, the Council decided to uphold Mr X’s safeguarding report about the August 2021 hospital stay. It said Mr X experienced harm and suffered neglect at the hospital. It recorded the risk to Mr X had now been removed and the hospital had identified four improvement actions/ learning points from the issues raised.
26. I am satisfied the Council sought detailed information from the hospital and properly considered the safeguarding outcome reached. It also satisfied itself the risk had been removed and actions taken to address the issues found. However, it was at fault in how it investigated this safeguarding concern for the following reasons.
1. The Council recorded it ended its enquiries about this incident in September 2022, a year after Mr X raised the concern. This was longer than it should have taken. It did not proceed in a timely way as set out in its policy. It took six weeks to decide if it should undertake section 42 enquiries, then a further eight weeks to discuss this with Mr X and seek information from the NHS. It did not record any reasons for these delays. Although it chased up the NHS for a response, it only did so five times over a nine-month period and took too long to escalate this to get a response. The Council did not properly monitor the delays, or agree any revised timescales with Mr X, as described in its policy. In response to our enquiries, the Council accepted it was at fault because it took too long.
2. The Council did not review the outcomes of the enquiry with Mr X before it was closed, or seek feedback about his experience of the enquiry, as set out in its policy.
3. The Council did not properly tell Mr X the outcome in writing until March 2023, after he had chased this and made a complaint. This was nearly six months after it made its decision about the enquiry outcome.
27. The Council’s failure to complete its safeguarding enquiries in good time, and to communicate with Mr X properly about this, caused him distress. I cannot say, even on the balance of probabilities, whether it would have changed anything for Mr X had the Council completed its enquiries sooner. This may have prevented Mr X experiencing similar issues during a later hospital visit in January 2022, had the investigation been completed and improvement actions for the hospital decided sooner. There remains uncertainty for Mr X about how things may have been different for him if the Council completed its enquiries for the first incident sooner. This uncertainty caused Mr X distress. The Council should provide a remedy for the injustice caused.

Safeguarding concern raised in February 2022

28. In February 2022, Mr X raised a safeguarding concern with the Council about care he received in hospital in late-January 2022. At this point the investigation into his earlier concerns about the August 2021 hospital stay was still ongoing. Some issues Mr X reported were similar to those he had reported about the earlier hospital stay. However, he also described other issues, such as that the hospital had refused to treat him and left him outside in a wheelchair in the cold for two hours. Mr X told me he felt this was the worst treatment he had ever had in a hospital. He saw this as the most significant of the safeguarding concerns he raised.
29. When the Council responded to Mr X’s complaint in March 2023, it at first said this February 2022 concern did not meet the threshold for it to undertake section 42 enquiries. When Mr X queried this further following the complaint outcome, the Council then provided conflicting information. It said it had undertaken enquiries about this second incident and had merged this with its investigation into the earlier, August 2021 hospital stay. I could not reconcile what the Council told Mr X with what its records showed. It held no records to show the enquiries had been merged, or that any information had been sought from the hospital about the later hospital stay, which happened five months after the first. This inconsistency was fault.
30. In response to our enquiries, the Council confirmed it had not properly considered Mr X’s February 2022 concern or made a decision about whether it should undertake section 42 enquiries. It had not investigated it further. The Council accepted it was at fault because it had not considered the concern properly. It also confirmed that had it considered this properly at the time, it would have decided this met the threshold for it to undertake section 42 enquiries. It therefore said it would re-open its investigation into this concern.
31. The Council was also at fault because it had opportunity to identify this fault when it responded to Mr X’s complaint but failed to do so. Mr X specifically raised that he did not think the Council had considered the February 2022 concern, and yet the Council told him it had, even though its records indicated otherwise. This was fault.
32. The Council’s failure to properly consider Mr X’s February 2022 concern, was fault. I cannot say, even on the balance of probabilities, what the Council may have decided had it considered this properly and investigated it further. However, there remains uncertainty for Mr X about how things may have been different, which the Council should remedy.
33. The Council’s failure to respond to the February 2022 concern caused Mr X significant distress. He had significant concerns about the care he had received during a hospital stay which he had found deeply distressing. This distress was worsened when the Council gave him conflicting and wrong information during the complaints process about how it had considered this safeguarding concern. The Council should provide a remedy for the distress caused.

Safeguarding concern raised in March 2022

34. In March 2022, Mr X raised a safeguarding concern with the Council about NHS district nursing care he received in his home in December 2021.
35. The Council’s handling of this safeguarding concern did not form part of Mr X’s March 2023 complaint to the Council. However, I considered it as part of my investigation. The law says we may investigate matters that come to our attention during an investigation if we consider someone may have suffered injustice as a result. We also may decide to investigate a complaint which has not first been raised with a council, if we consider it would be unreasonable to give it opportunity to investigate and reply. Mr X’s March 2022 concern about district nursing care happened within the period I investigated and before Mr X complained to the Council about its safeguarding procedures. Mr X told me he did not mention it in his complaint because the issues “paled in comparison” to the issues he experienced in hospital. However, the Council did not handle the March 2022 concern properly which caused Mr X an injustice. It also had opportunity to identify this when reviewing Mr X’s file as part of its complaint investigation. I therefore decided to consider it as part of my investigation.
36. In May 2022, two months after the Council received Mr X’s concern about district nursing care, it recorded its decision was this did not meet the threshold for it to undertake section 42 enquiries.
37. The Council was at fault in how it investigated this safeguarding concern for the following reasons.
1. When the Council acknowledged receipt of the concern in March 2022, it asked Mr X if he was now receiving the district nursing care he needed or if the issues were still ongoing. He told the Council the issues were ongoing, and he was still not receiving the care he needed. There was no evidence the Council responded to this or considered it as part of its investigation.
2. The concern was initially considered by a social worker a week after the Council received it. The social worker decided this did meet the threshold for the Council to undertake section 42 enquiries. A senior social worker then reviewed this two months later and decided the threshold was not met and the case should be closed. The Council recorded the outcome as “risk reduced – actions required”. The Council kept no records to properly explain its decision making about this, why it changed its decision, or what the actions were that it had determined were required on closing the case. It did not keep proper records of its decision and reasons in line with statutory guidance and its own policies.
3. There was no record the Council ever communicated the outcome of its consideration to Mr X.
38. The Council’s failure to properly consider Mr X’s March 2022 concern, was fault. I cannot say, even on the balance of probabilities, what the Council may have decided had it considered this properly or investigated it further. However, there remains uncertainty for Mr X about how things may have been different, which the Council should remedy.
39. The Council’s failure to respond to Mr X’s concern about this caused him distress. The Council should provide a remedy for the injustice caused.

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Agreed action

40. Within one month of our final decision, the Council will:
1. apologise to Mr X for the faults identified and the impact those faults had on him;
2. properly investigate and respond to the safeguarding concerns Mr X raised in February 2022 and March 2022, in line with statutory guidance and its own policies; and
3. pay Mr X a total of £1,300, comprising of:
1. £800 to recognise the avoidable distress caused by the uncertainty that remains about whether things may have been different for him had it properly considered all safeguarding concerns; and
2. £500 to recognise the avoidable distress and confusion caused by the Council’s failure to communicate with him and respond to his concerns properly.
41. Within three months of our final decision, the Council will:
1. review its administrative processes for handling adult safeguarding concerns to establish why it failed to consider Mr X’s February 2022 concern. It will then issue internal guidance to relevant staff to prevent reoccurrence of this issue;
2. share our final decision with relevant adult safeguarding staff to ensure they are aware of the Ombudsman’s findings in this case. It will ensure staff are aware of the Council’s learning points from our decision and the importance of:
1. clear and accurate record-keeping, including recording decision reasons;
2. keeping to timescales, monitoring delays, and keeping the subject of the concern and/or their representative(s) informed;
3. communicating outcomes to the subject and/or their representative(s); and
4. properly checking Council records when responding to complaints about adult safeguarding to ensure Council complaint responses are accurate based on its records and evidence.
42. The Council will provide us with evidence it has complied with the above actions.

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Final decision

43. I have completed my investigation. There was fault by the Council which caused avoidable distress for Mr X. The Council agreed to our recommendations to remedy this injustice, review relevant administrative processes, and share learning points from our decision with its adult safeguarding staff.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman