Date of decision: 19 August 2025
Summary
A friend raised repeated safeguarding concerns about the welfare of a possibly vulnerable man experiencing seizures, but the Council failed to act on multiple alerts from her, emergency services or from the police. The Council failed to safeguard the man and left him at risk of harm without support, resulting in eventual eviction. The Council’s poor complaint handling caused further distress to the man, his family and his friend.
What happened
From June 2023, Ms X reported concerns about Mr Y’s welfare, related to seizures he was experiencing, and the Council initially told her to fill out a safeguarding form. The Council received referrals from emergency services, the police, and others to the same effect.
Despite resending the form, and clear evidence of seizures leading to injury and property damage, hospitalisation, and potential eviction, the Council rejected Ms X’s safeguarding referral on procedural grounds in August 2023, and failed to evidence that it ever completed assessments required under section 42 Care Act.
The Council decided to allocate a social worker in June 2024, but it failed to contact Mr Y for a month and then only planned to visit a whole month later. A seizure in September led to a fall and Mr Y suffered a serious injury as well as eviction by his landlord, in October.
During this time, Ms X pursued a complaint but the handling of it was poor. The Council issued a Stage One (corporate complaint process) response. When Ms X asked to escalate to Stage Two, the Council misdirected her to resubmit it under the adult social care procedure as a new complaint. The Council then referred her to the Ombudsman.
What was found
Firstly, the Ombudsman found the Council failed to make necessary safeguarding enquiries when repeated referrals were received, including from professionals such as the police and emergency services. The Council failed to implement the thinking and exploration under section 42 of the Care Act 2014 needed to decide whether a further safeguarding enquiry was necessary.
The Council fettered its discretion by rejecting Ms X’s safeguarding referral because she “had not followed the correct process”, rather than considering the welfare concerns. This failure left Mr Y exposed to avoidable risk and uncertainty.
After one referral about Mr Y, the Council triaged the matter by recommending a referral to a doctor. The Council changed this recommendation after management oversight. The Council then recommended a care and support needs assessment and mental capacity assessments considering Mr Y’s ability to make decisions around his care and support and living situation. The Council confirmed it would meet his assessed needs and consider referrals to other agencies. The Council had not, however, evidenced it completed any of the actions it decided it should.
Moreover, the Ombudsman also found fault in the Council’s complaint handling. The Council failed to fully consider Ms X’s complaint and wrongly processed her complaint under the corporate complaints procedure instead of the adult social care route. The Council’s refusal to escalate the complaint and its delays in responding caused frustration and distress to Ms X. It should not have needed Ms X to resubmit a complaint because it did not do proper allocation of the complaint to the adult social care process.
The Council agreed to apologise to Mr Y and Ms X, pay financial redress of £2,000 to Mr Y and £200 to Ms X. The Council undertook systemic reforms such as undertaking a lessons-learned exercise, providing staff training on effective complaint handling and accepting safeguarding referrals as well as providing an update on the progress of the action plan to clear the backlog of email communications and police reports.
The Ombudsman seems to have probed to a further degree than is sometimes the case, in order to establish whether others might have been affected. The Council admitted it had a backlog of over 1,100 unread emails, including over 500 police reports.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
This case underlines the core statutory duty of councils under section 42 of the Care Act 2014 against a backdrop of well-established public law principles including taking account of all relevant considerations and excluding consideration of irrelevant ones, when discharging any statutory function.
In the 2024-25 year we note from the LGSCO dataset on councils that Haringey had 91% of 50 complaints that were investigated by the Ombudsman, upheld, and that 6 of them were about safeguarding. This decision was shared with CQC, which has already found that Haringey ‘requires improvement’ as part of its local authority assurance programme.
The Council’s refusal to progress safeguarding concerns because a referral form was not completed in the correct format demonstrates a fundamental misunderstanding of this duty. The law requires consideration of the substance of a safeguarding concern and avoidance of threshold policies that delay, obstruct, or block urgent intervention in cases where welfare risks are clear. A blanket rule that concerns cannot be accepted without a specific form unlawfully fetters the exercise of proper professional judgment and discretion and frustrates the statutory purpose of safeguarding functions.
Councils have a statutory duty to make enquiries under Section 42 of the Care Act 2014 if they believe a person may be at risk of abuse or neglect and because of their care and support needs, is unable to protect themselves. Once concerns are raised by professionals or members of the public, the duty to consider whether an enquiry is necessary arises and must be discharged competently and compliantly with public law rules.
In this circumstance, the Council did not assess Mr Y’s circumstances, leaving him at risk of harm. Failure to make timely safeguarding enquiries would be a breach both the Care Act and broader public law principles of fairness, rationality, and proportionality, exposing the authority to legal challenge. To prevent recurrence, the Council must review its safeguarding policy and provide staff training to ensure referrals are accepted and considered based on meeting the safeguarding threshold, regardless of whether a form is completed.
The Council used the wrong procedure and refused to escalate the complaint to Stage Two of the corporate process, demonstrating poor knowledge of the difference between the corporate scheme and the Local Authority Social Services and NHS Complaints Regulations 2009 which only has one stage. Councils must provide staff training on effective complaint handling, including identifying the appropriate procedure and resolving issues quickly using a common sense approach.
The Council was told to refer the investigation report, the lessons learned outcomes, and its action plans, to the Cabinet Member for Adult Social Care and the relevant scrutiny committee to ensure accountability and prevent future systemic failures. To our minds, this is failure at such a high level that someone’s job should be forfeited, in the interests of accountability.
The Council itself admitted that the case “was a serious oversight by several staff.” Councils must maintain adequate systems to respond promptly to incoming safeguarding referrals. Inaction in the face of backlogs can amount to administrative neglect and undermine the statutory purpose of safeguarding frameworks. As a remedy, the councils are required to ensure proper information management and provide an update on the progress of its action plan to deal with the backlog in email communications.
The broader implication is that safeguarding is not a procedural option but a legal obligation. Therefore, the councils should review and update their operational processes to ensure that no safeguarding alert is screened out. Councils must ensure frontline staff are well-trained to recognise referrals and must be acted substantively. The threshold for making safeguarding enquiries should be low and flexible to effectively safeguard vulnerable adults from any risks.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s London Borough of Haringey (24 014 203) report. If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
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