on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
Category : Adult care services > Safeguarding Decision : Upheld Decision date : 26 Feb 2026
What I found
A ction Final decision
The Ombudsman's final decision
Summary: Mrs X suffered distress and uncertainty because the Council failed to document its safeguarding decisions properly, failed to communicate with her properly and failed to follow up on a referral for a care line pendant. The Council will apologise to Mrs Y, make a payment to her, provide guidance to officers dealing with complaints and carry out a training session for those working in adult social care.
The complaint
The complainant, Mrs X, is represented by her daughter, Mrs Y. Mrs Y complained the Council: delayed acting to safeguard Mrs X despite multiple people raising concerns about neglect, financial mismanagement and social isolation; failed to follow up on mental health advice which included a recommendation for inpatient support for Mrs X; failed to communicate effectively with her.
Mrs Y says the Council’s failures have left her with uncertainty about whether Mrs X’s death could have been prevented and has caused her significant distress.
The Ombudsman’s role and powers
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) 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) When considering complaints 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.
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) Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
How I considered this complaint
As part of the investigation, I have: considered the complaint and Mrs Y's comments; made enquiries of the Council and considered the comments and documents the Council provided.
Mrs Y and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
What I found
The care and support statutory guidance A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. 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. (section 42, Care Act 2014) It should be noted that self-neglect may not prompt a section 42 enquiry. An assessment should be made on a case by case basis. A decision on whether a response is required under safeguarding will depend on the adult’s ability to protect themselves by controlling their own behaviour. There may come a point when they are no longer able to do this, without external support. (paragraph 14.17 of the care and support statutory guidance) People must be assumed to have capacity to make their own decisions and be given all practicable help before anyone treats them as not being able to make their own decisions. Where an adult is found to lack capacity to make a decision then any action taken, or any decision made for, or on their behalf, must be made in their best interests. (paragraph 14.55 of the care and support statutory guidance) The Council’s safeguarding adults policy When a safeguarding concern is received by the relevant team, the information contained within the contact form will be reviewed to determine whether the section 42 criteria appear to be met. If further information is required to support decision-making, it must be gathered as quickly as possible to aid decision-making. The views and wishes of the adult should also be sought in respect of what they would like to happen and whether they require the support of a relative, friend or independent advocate to engage in the decision-making process.
Not all safeguarding concerns will progress through the full safeguarding framework. If at the early decision-making stage it is deemed the risk(s) or concern has been resolved, then the safeguarding episode may end, and the reason clearly recorded.
What happened Mrs X was living at home with a care package and supported by her husband. Sadly, Mrs X’s husband died which prompted the Council to increase the care package in place. The Council also completed a referral for a care alarm and pendant.
In August 2024 Mrs Y raised concerns with the Council about Mrs X refusing medication and personal care. The Council contacted the care provider who said Mrs X had taken her medication but there was an issue about it being delivered to Mrs X. The social worker contacted Mrs Y about that.
Mrs Y contacted the Council later the same month to tell it she no longer provided support to Mrs X and believed Mrs X needed urgent input from the mental health team. The Council referred Mrs Y to the crisis team.
An occupational therapist contacted the Council to explain she had referred Mrs X to the community psychiatric nurse (CPN) and GP. The occupational therapist said Mrs X had plenty of food in the fridge/freezer.
Mrs Y contacted the Council to ask for a Mental Health Act assessment as Mrs X had attacked her son. The Council referred Mrs Y to mental health services and the GP. The Council contacted Mrs X who explained her son and daughter were helping her with shopping.
In September 2024 Mrs X told the Council she wanted to cancel the care alarm. Mrs X said she was not moving into sheltered care.
Mrs Y made a safeguarding referral to the Council on 1 November. Mrs Y raised concerns about Mrs X not having financial support, access to banking, social isolation, shopping and support. The social worker contacted Mrs X who said she was managing okay but had concerns around her health needs. Mrs X told the Council her son was supporting with shopping.
The Council arranged a care review. During that care review Mrs X asked the Council to reduce the number of care visits as it restricted her ability to go out. Mrs X told the Council her son would continue to support her with shopping. Mrs X said her son would accompany her to the bank to sort out some financial issues. Following that review the social worker contacted the care provider who raised no concerns about the change in care arrangements. Following that review an occupational therapist visited and confirmed Mrs X’s son was living with her and completing domestic tasks.
Mrs X’s GP surgery contacted the Council in December to raise concerns about Mrs X contacting it frequently. The GP surgery raised concerns about the care and support in place.
Shortly after that the Council became aware Mrs X’s son had left the property. The Council contacted Mrs X who confirmed that. The Council agreed to increase care and put in place meals on wheels for three days a week.
In December the crisis team became involved when Mrs X expressed suicidal thoughts. Mrs X’s son and the care provider also raised concerns. The Council contacted the crisis team. The crisis team told the Council they had spoken to Mrs X and she had been referred to bereavement services and the GP and that they would not be progressing the referral.
Mrs Y contacted the Council in December to raise concerns about Mrs X’s landlord saying he had not received rent. Mrs Y raised concerns about Mrs X’s ability to manage her finances. Mrs Y also raised concerns about inconsistent care support, social isolation, lack of family/friends support and cognitive challenges.
A social worker visited Mrs X and accompanied her to the bank. The bank consolidated the existing accounts and completed mandates to ensure bills were paid.
In December 2024 the Council received contact from the paramedics that had visited Mrs X as well as meals on wheels as Mrs X had said she wanted to end her life. The Council contacted the care provider who said Mrs X was becoming increasingly resistant and they had contacted the crisis team for support. The social worker contacted the GP who said a referral had been made for a Mental Health Act assessment.
The Council’s social worker accompanied Mrs X to the bank again later in December to complete further bank mandates. The social worker also noted the district nurse would visit Mrs X due to skin issues. The social worker noted those issues could have been resulted from Mrs X refusing care.
Later in December the care provider contacted the Council to tell it Mrs X had lashed out at carers and refused care. The care provider told the Council the crisis team had visited. The care provider intended to send carers to see Mrs X in pairs.
The care provider then put in a safeguarding referral. The care provider raised concerns there were too many risks and Mrs X was presenting as unwell. The care provider said it had contacted the crisis team and mental health services. The Council spoke to the GP and mental health services. The latter said Mrs X may benefit from a period of assessment in a mental health facility and although she had agreed she was presenting as well.
The CPN contacted the Council in December 2024 to raise concerns about Mrs X’s money and physical health. At around the same time the care provider told the Council it could no longer meet Mrs X’s needs and that she was refusing to let carers in. Mrs X also asked for a new care provider.
The Council contacted mental health services. Mental health services said it would not be conducting the Mental Health Act assessment or admitting Mrs X to a mental health unit following a joint visit with the crisis team as it was not required. Instead, the crisis team would attend Mrs X’s property that night to support the carers to give her medication. Mental health services told the Council Mrs X had food in the freezer.
When the care provider raised further concerns about Mrs X refusing medication and refusing to let carers in the Council spoke to the CPN. The CPN told the Council Mrs X’s behaviours were social and that not taking her medication would also make her unwell.
On 31 December professionals held a ‘Stop the Line’ meeting. The meeting agreed a joint visit by the GP and CPN for a clinical decision about whether Mrs X’s needs could be met at home or if she required admission to hospital.
In January 2025 the care provider again told the Council Mrs X would not let its carers in. The care provider explained one of Mrs X’s neighbours would buy shopping for her that day.
The Council contacted Mrs X’s GP. The GP said Mrs X had capacity to make a decision not to allow carers in and whether to take her medication.
The Council arranged a new care provider to take over.
The Council received a referral from the 111 service in January 2025 as Mrs X had reported not being able to cope at home and wanting to move to a care home. The Council’s social worker visited Mrs X and set up a new care package with a new provider. Once that had begun the Council checked with Mrs X and she said she was happy with the care provided. Mrs X also said the GP was to contact her about some skin issues.
Later in January the CPN contacted the Council to raise concerns about Mrs X’s finances. The Council also received a safeguarding referral raising concerns Mrs X was at risk of becoming homeless due to missed rent payments. The referral suggested Mrs X may be unable to manage her finances independently. The Council decided not to progress the matter to a safeguarding investigation as the social worker was dealing with it.
The Council’s social worker visited Mrs X and discussed her finances with the bank. That revealed the previous mandates Mrs X had completed had not been set up due to an error. The Council’s social worker supported Mrs X to make a one-off payment to the landlord and to agree a debt management plan.
In February 2025 the new care provider reported issues with accessing Mrs X’s money. The care provider raised concerns Mrs X’s bank card had been hacked. The care provider said it would accompany Mrs X to the bank so she could withdraw some money.
Mrs X’s landlord contacted the Council in March 2025 to report the bank had told him Mrs X’s rent payment would bounce. The Council’s social worker visited Mrs X and then spoke to her bank. The bank reported several large cash withdrawals over the previous few months which Mrs X could not explain. The social worker therefore raised a safeguarding referral. The social worker also referred Mrs X for a Mental Health Act assessment due to concerns about her ability to manage her finances. At the same time the social worker checked and noted Mrs X had plenty of food in the house.
Mrs Y contacted the Council to raise concerns about possible financial abuse. The Council began a safeguarding enquiry and contacted the police.
In March 2025 the Council also received an email from Mrs X’s landlord to say the process to evict her had been begun unless her arrears were paid in full. The social worker updated Mrs Y.
The Council carried out a mental capacity assessment about whether Mrs X had capacity to manage her finances. The assessment concluded Mrs X did not have capacity to manage her finances. Shortly after that Mrs X went into hospital. She later sadly died.
Analysis Mrs Y says the Council failed to act to safeguard Mrs X despite the fact many different agencies and people raised safeguarding concerns.
The documentary evidence shows the Council received many safeguarding referrals between August 2024 and March 2025. Those were from Mrs Y and other agencies involved in Mrs X’s care. However, the only safeguarding referral the Council progressed to an enquiry is the safeguarding referral in March 2025 about Mrs X’s finances. The issue for me to consider is therefore whether the Council dealt properly with the safeguarding referrals received before March 2025.
For the early concerns raised by Mrs Y and others I am satisfied the Council acted by increasing the care package in place and in completing a review in November 2024. I therefore could not say the Council failed to act during that period. The Council’s procedures are clear though that when a safeguarding referral is received the decision about whether to pursue an enquiry should be properly recorded. I am not satisfied the Council did that for each referral it received and that is fault. I do not consider that likely resulted in any injustice though given the measures the Council took in response to the concerns raised between August and November 2024.
It is clear though that throughout December 2024 the Council received lots of safeguarding referrals, including from Mrs Y, medical professionals and the care provider. The Council also knew Mrs X was regularly refusing care. Again, I am not satisfied the Council properly recorded what decision it had made about whether to pursue safeguarding enquiries at that point. That is fault.
I have to take into account though that a multiagency meeting took place at the end of December 2024 where all the concerns were considered. I therefore do not consider it likely, on the balance of probability, if the Council had recorded a decision about whether to pursue a safeguarding enquiry in December 2024 it would have resulted in a different outcome. As the GP said in January 2025, Mrs X had capacity to make decisions about her care and that included decisions about whether to take her medication.
I am also satisfied the Council dealt with the safeguarding referrals it received in January 2025 appropriately as it set up a new care package with a new care provider. The evidence the Council had by the end of January 2025 was that the care package was working properly.
I recognise though the Council received further safeguarding referrals about Mrs X’s finances in January and February 2025. I am satisfied the Council’s records show it decided not to pursue a safeguarding enquiry because the social worker was dealing with the issues. It is not the Ombudsman’s role to comment on the merits of a decision reached without fault. As the documentary records show the social worker had visited the bank in 2024 to set up mandates to pay bills and followed that up by visiting the bank to sort out the remaining issues early in 2025 I have no grounds to criticise it. The evidence I have seen satisfies me the Council did not have any evidence to suggest the possibility of financial abuse until the social worker visited the bank with Mrs X in March 2025.
Mrs Y says the Council, in deciding not to pursue safeguarding issues further, wrongly relied on Mrs X’s explanation of the situation. Mrs Y says the Council should not have done that due to Mrs X’s medical conditions which impacted on her cognitive ability.
I am satisfied though the Council did not rely solely on what Mrs X told it. The Council also spoke to Mrs X’s son, the care provider in place at the time, the GP, the CPN, an occupational therapist, the crisis team and mental health services. I therefore could not say the Council only relied on what Mrs X said.
Mrs Y says the Council failed to arrange for a care alarm to be fitted despite the fact she was told that would happen. The Council accepts it failed to follow through after making a referral for a care line pendant in August 2024. The Council believes that was because it understood Mrs X would be relocating into sheltered accommodation and therefore did not need the pendant. The Council accepts though it should have pursued the matter further.
The evidence I have seen satisfies me that by September 2024 the Council knew Mrs X would not be moving into sheltered accommodation. In those circumstances failure to follow through to ensure Mrs X received a care line pendant is fault.
Mrs Y says the Council failed to act when Mrs X cancelled meals on wheels. Mrs Y is concerned about that because she says Mrs X did not have sufficient food in the house. Having considered the documentary evidence I have found nothing to suggest the Council knew about Mrs X cancelling meals on wheels. I therefore cannot criticise it for failing to take action. I am satisfied though the documentary records show the Council made checks to ensure Mrs X had in place arrangements to ensure she had shopping.
Mrs Y says the Council failed to consider whether the care provider acted appropriately given it did not raise concerns and failed to take action on sores. The evidence I have seen satisfies me the care provider did raise concerns with the Council at various stages. As I said earlier, I am satisfied the Council took action in response to those concerns.
I understand Mrs Y’s concern though given Mrs X was admitted to hospital in March 2025 and was soon on end-of-life care. Mrs Y says Mrs X was dehydrated and had sores which should have been picked up by the care provider.
I cannot reach a safe conclusion about whether the care provider in place from January 2025 properly managed application of creams to Mrs X’s skin or carried out its tasks properly. That is because the care provider has changed its IT arrangements since the events complained of and no longer has the daily care records. Without those records I cannot reach a safe conclusion about whether the care provider documented any skin issues. I can say there is no documentary evidence to suggest the care provider raised concerns with the Council about those issues in 2025 though.
Mrs Y complains the Council failed to investigate the actions of the care provider when responding to her complaint. In response, the Council says it advised Mrs Y to complain direct to the care provider.
It is clear from the complaint Mrs Y put into the Council that she had raised concerns about carers not taking action to address Mrs X’s self neglect. Mrs Y had also raised concerns about the quality of care provided and identified specific issues. Given Mrs Y raised those concerns with the Council I would have expected the Council to respond. However, the Council’s complaint response, despite going into great detail about the chronology of events, provided limited responses to the issues Mrs X raised. That is fault. It is possible if the Council had made proper enquiries at that point it would have been able to access the care records that are now no longer available.
Mrs Y says the Council failed to follow up on mental health advice which was that Mrs X should receive some inpatient support. I am satisfied the Council followed up on that with mental health services which advised it had been decided that was not necessary, after a joint visit with the crisis team. As decisions around whether Mrs X needed inpatient support were a matter for the NHS, rather than the Council, I have no grounds to criticise it.
Mrs X says the Council failed to communicate effectively with her. The Council has accepted its communication with Mrs X was not always as good as it should have been. That is fault.
So, I have found fault in how the Council recorded its decision-making around the safeguarding referrals received. I have also found fault in how the Council responded to the complaint, in its communications with Mrs Y and in failing to follow up on the care line pendant. I consider because of the fault I have identified Mrs Y is left with some uncertainty about whether the situation would have been different had the Council acted appropriately. Mrs Y is also left with unanswered questions. To remedy that I recommended the Council apologise to Mrs Y and pay her £500. The Council has agreed to my recommendations.
I recommended the Council provide guidance to officers dealing with complaints about how to respond to complaints that also contain complaints about a care provider the Council has commissioned. The Council has agreed to that recommendation.
I further recommended the Council carry out a training session for officers in adult social care to cover the safeguarding process and the need to document decisions. The Council says it is currently commissioning a suite of safeguarding training modules for the forthcoming year which will be mandatory for all practitioners. As part of that the Council has agreed to carry out a review of its training for officers around the safeguarding process, including the need to document decisions. That revised training will then be mandatory for all relevant officers.
Action
Within one month of my decision the Council should: apologise to Mrs Y for the distress and uncertainty she experienced due to the faults identified in this decision. The Council may want to refer to the Ombudsman’s updated guidance on remedies, which sets out the standards we expect apologies to meet; pay Mrs Y £500.
Within three months of my decision the Council should: provide guidance to officers dealing with complaints about how to respond to complaints which include concerns about the actions of the care provider; confirm its progress with reviewing its training for officers around the safeguarding process, including the need to document decisions and advise when it expects to carry out mandatory training.
The Council should provide us with evidence it has complied with the above actions.
Final decision
I find fault causing injustice. The Council has agreed actions to remedy the injustice.
Investigator's decision on behalf of the Ombudsman