Date of decision: 11 November 2025
Summary
A woman (Mrs C), who holds power of attorney for her elderly relative (Mrs E), complained that the Council’s safeguarding investigation into her relative’s home care mishandled serious concerns about medication, diet and an unwanted hospital admission, while also investigating counter-allegations against her, from the care provider, without informing her in advance.
What happened
Mrs E was an elderly woman with several health conditions living in supported housing with on‑site care, receiving care visits from a care provider. Mrs C held power of attorney for Mrs E’s health, care and finances. Mrs C visited weekly, shopped and prepared food for Mrs E and managed a diet‑related condition alongside multiple prescribed medications, including painkillers, blood pressure tablets and an “as required” tablet for sickness and dizziness.
Before October 2024, Mrs E self‑administered the medications with supervision from carers and Mrs C. However, carers and a district nurse became concerned that Mrs E was forgetting when she had taken doses and was asking for more medication soon after receiving it, so the nurse advised the provider to take over medication administration.
In October 2024, the provider assumed responsibility and additional care visits were added, and carers began completing medication administration record (MAR) charts, which showed regular daily blood pressure medication but variable use of the two painkillers.
Mrs C believed carers were giving both painkillers together, instead of alternately, and she was unhappy that only three doses of the blood pressure medication were being taken in a week. She raised this concern with the provider but it did not investigate, despite her photographic evidence and her stance that she had removed any surplus tablets after a prior hospital discharge. The MAR charts showed the dizziness medication was given frequently but never more than three times a day.
At the end of October 2024, Mrs C made a safeguarding referral to the Council about pain relief and food intake, and checked with Mrs E’s GP, who confirmed the painkillers could be taken together or separately, though spacing doses might slightly improve pain relief.
At the same time, the provider raised a safeguarding concern with the Council about Mrs C, alleging she was controlling Mrs E’s food choices and finances, and was not acting in Mrs E’s best interests.
In November 2024, a member of the Council’s safeguarding team spoke to both Mrs C and the provider to understand their concerns and completed an assessment document drawing on information from health colleagues and the contracts team, on Mrs E’s medication, capacity and care. The information confirmed paracetamol should be taken four times a day and the second painkiller every four hours as required; GP records from 24 October noted untouched tablets from a 7 October delivery due to Mrs E’s hospital admission on 9 October and additional supplies on discharge, as well as recent deterioration in her short‑term memory.
The Council decided to carry out a single‑agency safeguarding enquiry under section 42 of the Care Act 2014 into both Mrs C’s concerns and the provider’s counter‑concerns, noting a communication breakdown between the agency and Mrs C, that left Mrs E “in the middle”.
Additionally, the Council stressed that Mrs E’s own views needed to be heard. A safeguarding practitioner (SGP) arranged a meeting for November 2024 to review her care plan and needs. Mrs C was also invited on the basis that Mrs E’s wishes would be heard. SGP also arranged to meet with the provider after the initial meeting with Mrs C and Mrs E took place. Notably, Mrs C was unaware of the allegations made against her prior to the meeting.
Subsequent to the meeting, the SGP told Mrs C it was unacceptable that both Mrs C and the provider had raised their voices in front of Mrs E. Furthermore, SGP stressed to Mrs C that Mrs E could express her views well in choice over meals.
SGP contacted Mrs E’s GP who clarified that no special diet was needed because Mrs E did not want further tests or treatment. The GP and dietitian agreed that choice and quality of life were priorities for Mrs E and said she had capacity when well, but some short‑term memory loss.
Mrs C supplied information about dietary requirements from a hospital dietitian and gave her account regarding the provider’s allegations against her.
On 20 November 2024, SGP spoke to the agency, who said Mrs E had recently been in hospital for several days due to a suspected stroke and the diet‑related condition, and that Mrs E had confirmed she wanted to remain in her current accommodation with care visits. SGP advised the provider that it must manage medication, keep accurate MAR charts including frequencies of requests, seek a GP medication review if Mrs E asked for pain relief too often, and ensure paracetamol was given four‑hourly with the other painkiller as required, as confirmed by the GP.
The provider also said Mrs C had returned the new contract for increased visits unsigned.
On 22 November 2024, SGP spoke to Mrs C about the hospital admission; Mrs C said Mrs E had been taken to hospital in November against her wishes and without Mrs C’s prior consultation. SGP said the paramedics had decided to take Mrs E to hospital because she had possible stroke symptoms and that not doing so could itself have been a safeguarding concern.
SGP visited Mrs E to review care visits, where they found Mrs E very happy with the care and thought visits were working well. The provider confirmed six daily visits and reiterated that Mrs C had not returned a signed contract. Mrs C later said Mrs E phoned her after this visit asking her to stop SGP “bothering her” and questioning SGP’s focus on Mrs C’s involvement. Mrs C said she had returned the contract marked as signed under duress so that Mrs E could receive care.
In December 2024, SGP wrote to the GP asking when paracetamol had been prescribed four‑hourly as well as whether there was any awareness of missed blood pressure tablets, and what Mrs E’s views were on the recent hospital stay. The GP confirmed that paracetamol had always been prescribed four‑hourly and never as required, that the hospital admission had been for the diet‑related condition but Mrs E did not want further admissions for that issue, and that blood pressure tablets had been prescribed since January with no record of missed doses being reported.
SGP also asked CP for evidence of any missed blood pressure medication over the previous two months and CP sent MAR charts from October showing no missed doses.
In January 2025, SGP closed the safeguarding enquiry as “partially substantiated” solely because paracetamol had been administered as required rather than four‑hourly as prescribed; after being added correctly to MAR charts and monitored, it was being given effectively.
The enquiry found no evidence of missing blood pressure medication and confirmed that painkillers were administered according to requirements. Dietary concerns were deemed appropriately addressed via professional medical advice. The allegations against Mrs C were not substantiated. Mrs E remained satisfied with Mrs C’s role as her attorney; consequently, all parties would continue to collaborate in Mrs E’s best interests while ensuring her voice remained central to her care.
In January 2025, Mrs C made a formal complaint to the Council about the safeguarding investigation and its outcome. In February 2025, the Council responded to this complaint and apologised that the purpose of the 8 November meeting had not been fully explained, that Mrs C had not been told beforehand about the allegations against her, and said SGP had not intended to put her in a difficult position; the Council accepted that, with hindsight, separate meetings would have been better. It acknowledged the enquiry outcome was confusing because both sets of concerns had been considered together, while the “partially substantiated” finding related only to paracetamol dosage and not to any allegation against Mrs C. The Council further stated Mrs E was clear she was happy for Mrs C to act as attorney for her finances, and it denied prioritising the provider’s concerns, saying it had a duty to consider all concerns even if that meant difficult discussions.
Mrs C remained dissatisfied and escalated her complaint to stage two while, during this period, Mrs E sadly died. In March 2025, the Council issued a stage two response, again saying it would have expected Mrs C to be told of the allegations before the November 2024 meeting, and explaining that she had been given a summary of the allegations with the January 2025 safeguarding outcome, confirming none had been substantiated and noting that safeguarding enquiries can take time.
Still unhappy, Mrs C received a third response from the Council in April 2025, which repeated its findings on medication and its view that there should have been two separate meetings at the outset. It confirmed Mrs E was content for Mrs C to advocate for her and that the concern about Mrs C was not substantiated, but also asserted that to protect the integrity of investigations it was standard practice to withhold information about accusations from the “source of risk” until inquiries were complete. Mrs C then complained to the Ombudsman.
The Ombudsman reviewed the law, policy and guidance, the Council’s records, Mrs C’s evidence and the safeguarding process. The Ombudsman concluded that the role was not to re‑run the safeguarding enquiry or decide whose factual account was right, but to examine whether the Council’s process contained fault that caused injustice to Mrs C.
What was found
The Ombudsman found no fault in the Council’s substantive handling of Mrs C’s concerns about medication and diet: it promptly sought medical information, clarified painkiller prescriptions with the GP, ensured CP corrected paracetamol dosing and MAR recording, checked blood pressure and dizziness medication records, and arranged practical steps so Mrs E could see food choices and exercise choice over meals. The Ombudsman noted that disagreements over events and allegations of altered MAR charts could not be resolved on the available evidence and that, once corrected, there was no ongoing risk to Mrs E from medication or diet.
The Ombudsman also found the Council had not prioritised the provider’s counter‑allegations over Mrs C’s concerns, because SGP’s records showed most attention was on diet and medication and the provider’s allegations largely fell away once it was clear Mrs E wanted Mrs C to continue supporting her.
However, the Council was at fault for failing to tell Mrs C in advance of the 8 November 2024 meeting that allegations had been raised against her and what they were, causing shock and contributing to the breakdown of that meeting in front of Mrs E.
The Ombudsman decided the Council was also at fault for not clearly and promptly telling Mrs C that the provider’s allegations were not being upheld, even though the Council appears to have reached that view before January 2025. This omission caused unnecessary uncertainty and distress. There was further fault in delay: the Council had effectively resolved most issues and decided the allegations against Mrs C were unsubstantiated by the end of November 2024, but did not reach a formal outcome until January 2025 because it waited until 10 December to seek information about alleged missed blood pressure medication and did not receive full responses until late December, extending Mrs C’s distress.
On complaint handling, the Ombudsman found the Council responded to Mrs C three times and accepted key failings, including not informing her of allegations in advance and not holding separate initial meetings, and apologised for these points. Yet the third response introduced a new justification—that it was standard practice to withhold allegations from the “source of risk” until investigations concluded—which conflicted with earlier acknowledgements and created confusion and additional upset for Mrs C.
The faults identified related to communication, timing and clarity, rather than to the core safeguarding risk assessment and protective actions, but they still represented maladministration, causing injustice in the form of distress, uncertainty and confusion for Mrs C.
The Ombudsman recommended, and the Council agreed, to apologise to Mrs C and pay her £200 within one month of the final decision in recognition of this injustice, with evidence of compliance to be supplied to the Ombudsman.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
All the people in this story all needed some legal advice, in our view.
The safeguarding practitioner needed more experience because in fact her instinct that it should all be dealt with together was not a bad idea – because the issues were, after all, all about the person in need, and her choices, her capacity and other people’s authority. She just needed to understand that one’s safeguarding title does not justify going around investigating allegations against people without telling them what they’re about, even if one keeps the source private.
The care provider needed to understand that medicating anyone without the consent of either the individual or their attorney is an assault. The opposite – failing to give people medication – can amount to negligence.
The welfare attorney needed to understand whilst it was open to her to assert that her grandmother lacked capacity, she had not done so. And that even if this was not a Council-commissioned service, but was privately funded, she couldn’t just withhold signing the provider’s contract, and imagine that that was in anybody’s best interests.
The woman in need needed to understand that she had granted a power of attorney that could only come into force once she’d lost capacity in relation to her wellbeing, and that the Council staff were not ‘bothering her’ but were seeking to get to the bottom of her capacity and wishes.
With regard to communication, the Ombudsman’s analysis in this decision treats the section 42 duty as satisfied once the authority has gathered multi‑agency information and taken reasonable protective steps. But community care law emphasises that any safeguarding enquiry remains a Care Act function and must be demonstrably compliant with the core public law duties of rationality, lawfulness and fairness across assessment, eligibility and care planning, not just within “safeguarding” boxes. This is not just because of the well‑being duty but because of public law’s most basic and essential requirements.
This ‘standard practise’ not to disclose allegations to the alleged perpetrator has been in place for over 30 years in Local Authority Settings even before safeguarding was made statutory. Councils seem unable to accept that they need to apply professional judgement to when disclosure would or could precipitate harmful consequences for the person who is the focus of safeguarding, or escape from police attention. It cannot BE blanket standard practise – and the investigator should have said this, in our view.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Suffolk County Council (25 001 276) 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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