The Ombudsman's final decision
Summary: Miss X complained about the decision of the Adult Safeguarding Board not to carry out a multi-agency review into events that took place prior to her daughter’s death. We have not found fault with how this decision was made.
The complaint
Miss X complains the Adult Safeguarding Board failed to take account of relevant information when making its decision not to carry out a review about events that took place prior to the death of her daughter. Miss X strongly believes that had the Board properly considered the facts it would have reached a different conclusion.
Miss X has suffered significant distress and frustration because of this decision. She feels her daughter was failed by the system and this should be acknowledged, and action taken to protect other vulnerable adults.
The Ombudsman’s role and powers
We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. 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) 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) We investigate complaints about councils and certain other bodies, including Adult Safeguarding Boards. We can investigate complaints about the actions of these bodies. (Local Government Act 1974, section 25(7), as amended) We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by: their personal representative (if they have one), or someone we consider to be suitable.
(Local Government Act 1974, section 26A(2), as amended) 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)
What I have and have not investigated Paragraph four (above) is relevant to this complaint.
Although the complaint is about events that occurred in 2020, the Council has corresponded with Miss X since this time. However, the Council did not provide its final response until September 2023 and Miss X complained to the Ombudsman shortly afterwards. I have therefore used my discretion to investigate this late complaint.
I have only investigated the decision making of the Adult Safeguarding Board, not the actions of either the Council’s adult or children’s services departments prior to Miss B’s death.
How I considered this complaint
I considered information from Miss X and the Council. I spoke to Miss X. I read the relevant law, guidance and policy. I also watched a video recording of a meeting between Miss X and members of the Adult Safeguarding Board.
Both parties had an opportunity to comment on my draft decision. I considered comments received before making a final decision.
What I found
Adult safeguarding Safeguarding Adult Boards Every council must set up a safeguarding adult board (SAB) for its area to help and protect adults who have care and support needs, is experiencing or is at risk of abuse or neglect and is unable to protect themselves from that neglect or abuse or risk of neglect or abuse.
Safeguarding Adult Reviews (SAR) The Care Act 2014 (section 44) states a SAB must carry out a review if: an adult with care and support needs (whether or not the local authority has been meeting those needs) has died; it knows or suspects the death resulted from abuse or neglect; and there is reasonable cause for concern about how the SAB, members of it or other persons worked together to safeguard the adult.
The SAB has a discretion to carry out a review even if the criteria above are not met. The local safeguarding adults policy states a discretional review can relate to an adult who does not have care and support needs (but might have just support needs).
The purpose of SAR is to identify any lessons to be learnt and apply those lessons to future cases.
What happened I have set out below a summary of key events. It is not intended to be a detailed account of everything that happened.
Miss X’s adult daughter (whom I shall refer to as Miss B) died in 2020.
Miss B was a vulnerable person. She had a diagnosis of autism, she had a learning difficulty and suffered with post-natal depression.
Several agencies were involved with Miss B prior to her untimely death.
Miss X believes her daughter was badly let down by these agencies, including the Council’s adult and children’s departments. Amongst many concerns, Miss X says: the Council failed to meet Miss B’s eligible care and support needs in the months prior to her death; the Council failed to offer Miss B appropriate support when she transitioned into adulthood. Miss B had been identified as a child in need and still had an Education, Health and Care Plan; and the Council incorrectly decided she was not eligible for a package of support from adult care services.
The local health board carried an investigation and referred Miss B’s case to the SAB.
Miss X also asked the SAB to carry out an adult safeguarding review into the circumstances that led up to Miss B’s death. She felt this was necessary because she felt several agencies had failed to take into consideration Miss B’s extreme vulnerability, her abusive relationship, a previous assessment that determined Miss B lacked capacity to make certain decisions about her own welfare, her learning disability, her autism and a diagnosis of an emerging personality disorder. Miss X felt this amounted to neglect and had directly contributed to Miss B’s untimely death.
The SAB considered the case. Although Miss X submitted written information explaining why she believed a review should take place, she was not given the opportunity to present this in person. Miss X says her written submission was only part of the story, and she had more information that the SAB should have been given the opportunity to consider.
The SAB decided the criteria for a review were not met because Miss B did not have eligible care and support needs. Prior to her death Miss B requested support from the adults services department. The Council carried out a screening assessment but decided she did not qualify for a service.
The SAB also considered whether use its discretion to carry out a non-statutory review. It decided not to do so.
Miss X challenged this decision. She was invited to meet with the SAB chair who explained why the Board had made its decision. Miss X was told that although the criteria for a SAR were not met, this did not mean that individual agencies could not carry out their own reviews as to what happened and what lessons could be learned.
Miss X made a complaint to the Council refused to accept the complaint for reasons of confidentiality.
Frustrated by this outcome, Miss X brought her complaint to the Ombudsman.
In response to my enquiries, the SAB explained the rationale behind its decision not to carry out a SAR. In summary, it confirmed the panel members decided unanimously that the case did not meet the statutory criteria because Miss B did not have care and support needs in the context of the Care Act.
Analysis The Ombudsman is not an appeal body. It is for the SAB, not the Ombudsman to decide whether the criteria for a SAR are met.
The SAB was not obliged to carry out a safeguarding enquiry just because a referral had been made and Miss B was a vulnerable person. It had to apply the criteria set out in the Care Act 2014, section 44.
I am satisfied the SAB followed the correct procedure in this case because: it took into consideration evidence that was provided by representative agencies, including health professionals, adult and children’s services; it took into consideration information provided by Miss X. Whilst Miss X felt she should have been given the opportunity to both attend the Board meeting and present more information, there was no obligation on the Board to facilitate this. It was for the Board members to determine whether it had sufficient information to make its decision.
it considered using its discretion to carry out a non-statutory review but decided not to.
I recognise that Miss X strongly disagrees with these decisions. However, the law does not allow the Ombudsman to question the SAB’s professional assessment of whether a safeguarding enquiry should be carried out if there was no evidence of fault in the way that the decision was made. I cannot call the merits of a properly made decision into question, however strongly others may disagree.
For this reason, I have not found fault.
Final decision
I have not found fault with how the SAB made its decision not to carry out a review. On this basis, I have completed by investigation.
Investigator’s decision on behalf of the Ombudsman
Investigator's decision on behalf of the Ombudsman