Date of decision: 24 Jun 2025
Summary
This complaint highlighted Kent County Council’s safeguarding actions against an informal carer for their partner with dementia. The carer was subject to an extended investigation, significant delays, and failures in complaint handling, resulting in distress, lack of support, and escalated mental health strain.
What happened
A health professional raised safeguarding concerns on 17 November 2023 about the care being given by the complainant to her partner with dementia, triggering the Council’s legal duty to investigate. [We think without being sure that the person with dementia did not yet have a Care Act status and that the only agency involved with the couple was the NHS.]
The complainant, about the Council’s approach to the safeguarding referral, was someone who held lasting powers of attorney.
The Council failed to contact either Mr D or Ms C for weeks, delaying allocation of an Investigating Officer (IO) until 2 January 2024.
By that time, Mr D was in a respite placement where Ms C had arranged for him to go, given that she was exhausted. Ms C explained how, and why she distrusted the NHS, and Mr D’s prescribed medication, their sleeping arrangements and the support Mr D had tried. Ms C said she was reluctant to have people visit their home because of the way it looked. Ms C expressed how difficult she was finding caring for Mr D. The IO asked to visit Ms C but she declined saying that Mr D would be returning by the end of the week and it was not convenient. Within a week or so of Mr D’s return home, Ms C contacted the Out of Hours social care team saying that she could no longer cope with caring for Mr D and would be making him homeless. Ms C again expressed how desperate she was for help and that she could not care for Mr D.
Mr D went into hospital on 23 January. The next day the IO explained she had referred Ms C for a carer’s assessment and was arranging an assessment bed for Mr D for when he left hospital. Mr D moved into an assessment bed on 26 January, having agreed to that plan.
On 15 February after some dead ends in progress, Ms C finally agreed to attend a meeting and had a carer’s assessment on 21 February. The carer’s assessment identified Ms C said Mr D could return home if the Council provided extra care of eight hours per week. Mr D ultimately moved from the assessment unit to Ms C’s preferred residential care home on 7 March.
Multiple agencies became involved as the partner moved between home, respite care, hospital, an assessment unit, and a care home, all while the carer herself was in crisis, repeatedly asking for help and refusing some support, due to exhaustion and distrust.
Communication was inconsistent; the Council offered assessments and advocacy, but meetings were missed or cancelled due to the complainant’s condition.
The outcome of the safeguarding investigation was that some allegations were confirmed but the risks were mitigated by Mr D’s placement. The safeguarding was closed but could be reopened should any further concerns arise. It does not appear the Council told Ms C about the closing of its investigation.
Ms C later complained about both the safeguarding process and care for her partner at the assessment unit. Some complaints remained unaddressed.
Mr D eventually moved back home with Ms C with care arranged by Ms C and funded by Mr D. In September 2024 Ms C had a further carer’s assessment and was offered several services including:
- a telephone line for emotional support;
- face to face support group for Ms C;
- a care agency to provide a service so Ms C could go out once a week.
The OPG assigned an investigator who found no reason to revoke the LPAs. Ms C remains responsible for Mr D’s finances and decisions related to his health and welfare.
The Kent and Medway policy regarding safeguarding said this:
- The Policy says initial safeguarding enquiries will take into account a range of factors to decide the next steps which include:
- a decision about whether the case reaches the criteria for a Statutory s42 Enquiry;
- reliability/credibility of the information received and need for any emergency or other protective action…..;
- impact of the alleged abuse on the adult(s);
- capacity of the adult(s) in relation to decisions regarding the safeguarding
- consideration of advocacy at the earliest possible point. The Council has to arrange an independent advocate to represent and support an adult who is subject to a safeguarding enquiry if the adult has substantial difficulty on being involved in the process and where there is no other appropriate person to represent them;
- vulnerability of the adult(s);
- length of time it has been occurring;
- information about the person(s) alleged to be responsible for abuse or neglect.
- The Policy says the Council should give feedback to the person alleged to have caused harm. It says,
- “An evaluation should be carried out as to whether it is safe to share information about the complaint with the person allegedly responsible. ………
- Providing information on the nature and outcomes of concerns to people alleged to have caused harm also needs to be seen in the wider context of prevention; for example, information can be used to support people to change or modify their behaviour. The person/organisation that is alleged to be responsible for abuse and/or neglect should be provided with sufficient information to enable them to understand what it is that they are alleged to have done or threatened to do that is wrong and to allow their view to be heard and considered. Whilst the safety of the adult remains paramount the right of reply should be offered where it is safe to do so. Decision making should take into consideration:
- The possibility that the referral may be malicious
- The right to challenge and natural justice
- Relationship dynamics
- Whether it is safe to disclose particularly where there is domestic abuse
- Compliance with the Mental Capacity Act 2005
- Feedback should be provided in a way that will not exacerbate the situation or breach the GDPR.”
What was found
The Ombudsman found no fault in the Council’s initial decision to start the safeguarding process: s42 imposes a statutory duty under the Care Act 2014, requiring investigation where abuse or neglect are suspected and the person’s care and support needs make it difficult for that person to protect themselves.
The report cited para 14.46 of the Guidance:
“Assessment of both the carer and the adult they care for must include consideration of the wellbeing of both people. Section 1 of the Care Act includes protection from abuse and neglect as part of the definition of wellbeing. As such, a needs or carer’s assessment is an important opportunity to explore the individuals’ circumstances and consider whether it would be possible to provide information, or support that prevents abuse or neglect from occurring, for example, by providing training to the carer about the condition that the adult they care for has or to support them to care more safely. Where that is necessary the local authority should make arrangements for providing it.”
Furthermore, the Council’s delay in progressing the action plan and its failure to inform the carer promptly, when safeguarding closed, amounted to maladministration and procedural fault.
The Council was also at fault for failing to revisit all the carer’s complaints after safeguards ended, breaching complaint-handling regulations. These failures caused significant distress, frustration, risk of deterioration for both carer and cared-for, and undermined trust even further.
On the plus side, the record-keeping was detailed and safeguarding was person-centred. This both showed the steps officers took and their decision-making.
The Council:
- spoke with Mr D several times;
- provided advocates for both Mr D and Ms C;
- when officers could they completed a mental capacity assessment of Mr D;
- spoke with Ms C on several occasions;
- offered Ms C a carer’s assessment on several occasions;
- completed a carer’s assessment for Ms C;
- spoke with other involved people/professionals as part of the safeguarding process;
- considered information from various sources including Ms C before making safeguarding decisions;
- produced action plans which officers then followed or explained why they could not follow them at the time;
- made a considered and proper referral to the OPG.
However, given the rule of natural justice the Council should have told Ms C when the safeguarding was closed and should have followed its own policy.
The Council was at fault for failing to revisit Ms C’s complaint about care provided to Mr D at the assessment unit, after the Council completed the safeguarding; failure to have done that was an injustice for Ms C.
No financial compensation was awarded, but apologies and follow-through on outstanding complaints were required.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The Ombudsman made a decision that the complaint about the care provided to Mr D at the assessment unit could not proceed. The investigator did so on the footing that Ms C was not a suitable person to bring the complaint, due to the fact of the safeguarding investigation, which had ultimately found little of concern.
We think that this is confused thinking, linked to the fact that the Ombudsman seems to think that there is an obvious discretion in the complaints regulations for Councils, themselves, regarding declining to consider complaints during anything to do with safeguarding. We have criticised that position already elsewhere for breach of public law principles.
Here, the stance of the Council and the stance of the Ombudsman, beg the important question namely who else could possibly have been expected to stand up for Mr D?
If this woman had been granted powers of attorney of both sorts by Mr D, that factor should not, in our view, have been undermined by the Ombudsman’s acquiescence in the Council’s own minimalised approach to that status and to the trust it represented. A complaint is a complaint, and a person holds power of attorney until it is revoked. They are best interests decision makers and consultees regarding others’ duties, until the status is removed by the Court. The OPG officer to whom the Council left that decision did not seem to think that there was a problem of such an extent as to justify a revocation application.
The Ombudsman’s report reiterates that councils have a legal duty under section 42 of the Care Act 2014 to make safeguarding enquiries wherever there is a reasonable cause to suspect that an adult with care and support needs is at risk of abuse or neglect and cannot protect themselves by reason of those difficulties.
The Care Act and its Statutory Guidance emphasise a person-centred, proportional approach, involving both the cared-for person and any carer, and require joint assessments to consider the well-being of all parties. Informal carers are not only potential sources of risk but may themselves be at risk of abuse and needing support, assessment, and preventative services in their own right.
The law and guidance make clear that safeguarding processes must facilitate timely information sharing and advocacy, ensuring the person allegedly posing the risk is given appropriate feedback, the opportunity to respond, and is informed of outcomes in a safe manner. These are all basic public law principles of fairness, rationality, due process and transparency.
Community care law indicates the local authority’s duty extends beyond simply reacting to a safeguarding alert: it must prevent escalation and deterioration by acting without delay and providing comprehensive, independent carer’s assessments. Several decided judicial review cases have stressed that procedural fairness, clear communication about key decisions, and adherence to the six safeguarding principles are not optional but foundational legal obligations. Local authority breaches—or delays—in assessment, planning, or proper engagement with carers (whether or not under the shadow of a safeguarding investigation) can result in unlawful decisions and expose councils to challenge. The need for advocacy and supported decision-making is mandated where substantial difficulty is evident, and assessments must be properly documented and actioned.
Council personnel must be clear on these legal requirements and not treat compliance as a discretionary aspect. Ongoing compliance reviews, staff training, and clear written protocols are indicated to reduce risk of repeat failings and ensure that councils meet statutory duties, uphold rights, and protect both service users and carers at all stages. These legal duties exist to prevent deterioration and distress—the practical consequence of failure is avoidable harm, which can and does have significant lifelong effects for all involved. Readers and practitioners are reminded that community care law, not local policy nor the ombudsman’s findings of fault, provides the ultimate legal benchmark for proper practice.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Kent County Council (24 008 301) report.
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