Date of decision: 07 October 2025
Summary
A man complained that the Council’s care provider did not follow adult social care procedures, failed to meet Deprivation of Liberty Safeguards (DoLS) conditions, and did not respond properly to complaints, causing his family distress. The provider’s lack of communication and procedural delays prevented the family from understanding and challenging decisions about the care and liberty of their relative.
What happened
In February 2024, an individual requiring full-time care moved to Care Home 1, run by Care South on behalf of the Council. In April 2024, the individual was assessed and found to lack capacity to make decisions about his care. He was placed under the DoL Safeguards and conditions were attached to the DoLS authorisation. The Council conducted a DoLS review in July 2024.
In August, a family member raised complaints about ,failure to comply with actions from DoLS recommendations, frequency of unwitnessed falls, unprofessional conduct from a manager, and general staffing levels. The care provider passed the complaint to its Operations Manager. The family member requested his complaint be dealt with at stage 2 of its three-stage complaints policy as he thought that the Operations Manager might not be able to be objective.
The stage 2 response in September 2024 did not uphold the complaint. It stated that while reporting about incidents was inconsistent, they believed it met DoLS conditions and that information was being shared, though care notes could not be provided. Specific falls were investigated and information about them was provided. Staffing was judged adequate.
The complainant remained dissatisfied, noting that in his opinion emails he received fell short of the intent of the DOLS recommendations. Issues raised to the Chief Executive went unanswered, and he wanted an explanation about actions being taken to reduce the number of falls, the rationale for and outcome from a meeting with the manager whose conduct he complained about, and reduced family attendance at the care home.
A review of the conditions attached to the individual’s DoLS took place in July/August 2024. This found that the Care Provider only partially met the condition in relation to recording information about the individual.
The provider responded at stage 3 in late September, covering areas of the initial complaint, together with further information about communication sent in error, falls prevention and family attendance. It did not specifically answer the further issues the family member raised with the Chief Executive.
Meanwhile, the individual moved to a different home. The provider failed to meet the timeline for the acknowledgment of the initial complaint within 10 days after it was submitted and did not answer the family member’s complaint properly at Stage 3. It did not fully comply with the DoLS conditions to share information. The Care Provider and family member had arranged to hold weekly meetings to facilitate communication but the family member said these had stopped. The August review added a recommendation for adult social care staff to liaise with the care provider to ensure previously agreed actions should happen as soon as possible and to be reviewed. The Council accepted that the family member asked it for provision of ABC charts in August and that there was no evidence that it requested this information from the care provider, or that the information was provided. The failures caused avoidable distress for the family.
What was found
The Ombudsman found the Council and Care South at fault for failing to comply fully with the DoLS conditions regarding information sharing.
The family member said this denied him the opportunity to understand the legal and clinical basis for his father’s deprivation of liberty, to verify whether the safeguards were being properly applied, and to challenge or question any aspect of the authorisation that might have affected the individual’s rights, dignity or care. This lack of transparency obstructed the family member’s role as an informed advocate and undermined the principle of accountability.
The Ombudsman agreed that the family member suffered avoidable distress as a result of this fault.
To remedy the fault the Ombudsman recommended that the Council should apologise to the family for not complying with the DOLS conditions and not providing information. It should also pay £200 as compensation for distress.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The Ombudsman’s focus in this decision rightly emphasises the responsibilities flowing from the Deprivation of Liberty Safeguards and complaints procedures, but it does not fully situate these duties within the broader statutory context set by community care law. The Care Act makes clear that public authorities are under an express duty to promote well-being, safeguard rights, and ensure procedural fairness when considering decisions about care and liberty, as reinforced by public law principles and case law.
Key omissions from the Ombudsman’s legal reasoning include detailed reference to the explicit Care Act 2014 duties regarding meaningful involvement in decision-making, as well as the requirements to ensure accessible information so that individuals—and their families—can challenge or scrutinise decisions effectively.
In public law, failure to keep families adequately informed and involved can amount to a procedural flaw, undermining the lawfulness of key decisions. The duty to involve appropriate representatives—including family and, where necessary, independent advocates—where an individual lacks capacity, is not discretionary but statutory (the advocacy, unless a person has someone informally willing and appropriate to support their participation). The obligation to communicate regularly and share records is not simply good practice: it is central to the article 8 human right of respect for private and family life and to the proper operation of the safeguards envisaged by relevant statutes.
The report is silent as to the precise legal role of the family member although it seems likely that he was the Relevant Person’s Representative (RPR) whose role is described in the DoLS Code of Practice.
If that was the case there is force in his argument that in order to fulfil his role properly he required full information. The Code of Practice emphasises the importance of the RPR’s role which includes a responsibility to represent and support in all matters including triggering a review, using complaints procedures and making an application to the Court of Protection.
There were clearly concerns about the individual falling, and full information might have revealed serious failings. We know that the individual did move eventually although we do not know why.
The Code of Practice also stresses the importance of the RPR having contact with the person, and in that context it is particularly concerning that family contact in this case appears to have been limited, at least at some stages – there is a reference to reduced family attendance at the home, and this seems to be referring to that reduction being requested by the Home. In the absence of agreement about contact authorisation would be needed from the Court of Protection but it is unclear if the family member was aware of this, or if he was given any information or guidance on this point by the professionals involved.
Failure to share information can impede an RPR in their responsibilities in relation to complaints, and reviews, but also in assisting the person to apply to the Court of Protection to challenge the deprivation of their liberty under Mental Capacity Act 2005 s. 21A.
The investigator makes a startling error in asserting that the Deprivation of Liberty Safeguards provide legal protection for individuals who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation. This last bit is simply not true.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Bournemouth, Christchurch and Poole Council (24 011 583) 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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