Date of decision: 11 May 2026
Summary
A father complained that the Council‑commissioned transport staff and police’s handling of his autistic, non‑verbal son during a journey to college caused avoidable distress, and that the Council’s safeguarding response and complaint handling were seriously delayed and inadequate.
What happened
Mr C is autistic, non‑verbal and lacks capacity to make decisions, with his father Mr B acting as his court‑appointed deputy to make decisions on his behalf. Mr C regularly attended college using a Council‑commissioned transport provider, Transport X, with two transport assistants supporting him.
In September 2024, while Transport X was taking Mr C to college along a busy main road, Mr C suddenly became agitated in the vehicle and attempted to assault one of the assistants. The driver stopped the car in the road; the assistants got out and flagged down a passing police car, leaving Mr C alone and distressed in the vehicle. Police officers handcuffed Mr C because of his distressed behaviour and difficulty in regulating himself, and considered taking him to hospital with a view to sectioning him under the Mental Health Act. A passing member of college staff intervened at the roadside, calmed Mr C down, and the police, having spoken to Mr B who warned a hospital visit would cause greater stress, ultimately decided not to take him to hospital.
The next day, both the college and the police informed the Council of the incident and said Mr C had sustained bruising. The Council started the safeguarding process and allocated the case to a social worker (SW), who arranged a multi‑disciplinary team (MDT) meeting and spoke to Mr B to obtain his views.
Separately, the Council’s Transport Service carried out its own investigation and produced a report identifying two unsafe behaviours by Transport X staff: leaving the vehicle and failing to report this immediately to college staff or their line manager, and not using any de‑escalation techniques to calm Mr C. The transport report suggested possible recommendations for refresher training for the transport assistants in safeguarding passengers and positive behaviour training to provide different techniques.
The MDT took place on 3 October 2024. The SW explained she had tried to speak directly to the travel assistants and driver, but Transport X refused and instead directed her to the manager of the Council’s transport team, limiting direct evidence‑gathering. Mr B said he could not identify triggers for Mr C’s behaviour that day, noted that Mr C was now using new transport in a larger vehicle which was working well, and expressed his view that the police’s involvement and use of handcuffs had been disproportionate. The MDT agreed that the SW would gather further information from Mr C’s family, the college, the transport team and the police, follow up with the safeguarding team and report back to the MDT.
On 9 October, the SW fed back her initial findings and conclusions to all parties, stating she was closing the case because the safeguarding threshold had not been reached. On 17 October, two senior officers emailed all parties confirming they would not proceed with a safeguarding investigation, reasoning that there was no evidence of abuse or neglect, that Mr C’s bruising was attributable to police attempts to manage immediate risk rather than mistreatment, that the behavioural escalation was sudden even to staff familiar with Mr C, that no concerns had been passed from the college to the transport service before the journey, and that Mr C had shown no prior indication of distress. The Council concluded that the safeguarding threshold was not met, and instead proposed future risk prevention work to support Mr C during transport and learn from the incident.
The initial investigation report did record that the travel assistants had not informed the police of Mr C’s health conditions, but it concluded this omission was unlikely to have altered the police response, a conclusion with which Mr B disagreed. Following disagreement from Mr B and the college, the Council held an internal meeting of senior staff to review the case and decided to uphold its view that the threshold was not met, maintaining that the risk‑mitigation plan was a proportionate response.
In December 2024, after receiving further information from the college and a neighbouring council, the Council accepted that more discussion was needed and convened another MDT on 10 January 2025, which Mr B attended. At this meeting, the MDT agreed that the safeguarding threshold was met and that the SW should reopen the case and carry out a full safeguarding enquiry. The Chair of the meeting said a written report would be sent within four weeks, apologised for the incident and for the handling of the investigation to date, and stressed the importance of transparency and accountability.
On 14 February, the Chair said they were unhappy with the AI transcription of the January meeting because it had captured almost none of the discussion, so the minutes required reconstruction and further work and would be sent within a week. Mr B chased the Council for the minutes, and the Council agreed to send them by the end of February, but the SW did not issue them until 7 April, apologising for the delay but giving no reasons at that time; the minutes themselves were brief, only around a page and a half.
On 4 April, frustrated by the delay and lack of progress in the safeguarding investigation, Mr B made a formal complaint to the Council. The Council responded on 13 June, stating it had carried out a full enquiry and that the safeguarding report would be sent to him by 24 June, summarising key findings in its complaint response. It explained that the police had not been informed of Mr C’s health conditions and had apologised for the distress caused, and that the police would review the incident through their learning and development processes. The Council said it had reinforced with the transport team the importance of sharing vital information about service users, noted that Mr C had been referred for art therapy to help with the impact of the incident, and that he now had a new driver and escort with relevant training, a new risk assessment, and that refresher training on safeguarding and positive behaviour support had been provided to the travel assistants involved. It also said it had introduced new procedural measures for transport service‑users to ensure more consistent, better‑informed support.
On 14 June, Mr B requested a stage two review of his complaint. On 23 June, the Council replied, apologising for failing to include a crucial paragraph explaining that complaints about Adult Social Care provision were handled through a one‑stage complaints process, meaning that he should now complain to the Ombudsman instead of expecting a second stage. By 8 July, Mr B still had not received the promised safeguarding enquiry report, so he complained to the Ombudsman.
The Council only sent Mr B the full safeguarding report on 5 December 2025, accompanied by a letter of apology but still without an explanation for the delay. On 14 December, Mr B wrote back asking for the reasons for the delay and pointing out discrepancies and inaccuracies in the report, including issues about the transparency, thoroughness and competency of the initial investigation, the initial conclusion that the safeguarding threshold was not met, and the unexplained delay in issuing the January MDT minutes.
In response to the Ombudsman’s enquiries, the Council later explained that the AI system used to transcribe the January meeting had failed, capturing almost none of the discussion, which required reconstruction and sign‑off of the minutes and caused delay. It also said the manager responsible for finalising the safeguarding report had been absent from work, contributing to the delay in sending the report, but gave no convincing justification for why the delay became almost six months.
What was found
The Ombudsman found the initial safeguarding decision‑making was flawed, the enquiry and communication were subject to repeated unjustified delays, and the Council accepted the need to apologise, make a symbolic payment, provide agreed support and strengthen its safeguarding and complaints procedures.
The Ombudsman accepted that Mr C’s behaviour escalated suddenly in a familiar situation and that the incident itself could not reasonably have been predicted, so there was no clear fault in the fact of the behavioural crisis. However, the way the incident was handled raised serious concerns: stopping the car in a busy street appears to have exacerbated Mr C’s distress, Mr C was left alone and very distressed in the vehicle, the travel assistants attempted no de‑escalation, and they failed to inform the police of Mr C’s health conditions, putting him at risk of even greater distress and potentially inappropriate intervention. The Ombudsman considered it fortunate that the police were passing and the more so that the member of the college was able to calm him down. Without this intervention, it was likely he may have been taken to hospital and possibly sectioned which would have greatly exacerbated his distress. The Ombudsman was unable to say the incident happened due to fault by any party but the way it was handled was open to question.
The Ombudsman found that the transport team manager’s initial conclusion that there were two possible faults to be addressed with training did not logically support the senior officers’ October 2024 decision that the matter did not meet the safeguarding threshold. That first safeguarding decision‑making process was flawed because it focused solely on the unexpected nature of Mr C’s behaviour, ignored identified possible fault by staff, and failed to consider the risks of the situation Mr C was left in or the possibility that similar circumstances could recur, thereby failing properly to address Mr B’s safeguarding concerns. The conclusion that failing to inform the police of Mr C’s conditions did not affect the outcome was speculative and unsupported by evidence, causing uncertainty for Mr B about whether the incident had been properly considered.
The Ombudsman did not criticise the Council’s later change of position: within just over six weeks, following input from the college, Mr B and other parties, the Council accepted the threshold was met, reopened the case, and commissioned a full enquiry from the original social worker, along with an apology for the earlier handling. The final report recognised fault by the travel assistants for not informing the police of Mr C’s conditions and not using de‑escalation techniques, and recorded that training and procedural changes had been implemented, which the Ombudsman considered showed that the second decision‑making process was more thorough and substantially addressed Mr B’s concerns.
However, the Ombudsman found significant fault in repeated, cumulative delays. The Council failed to send minutes of the January 2025 MDT within a reasonable time: they should have issued them by about 17 January but they were not sent until 7 April, nearly three months late, and at the time no explanation was provided to Mr B, even though the minutes were only about a page and a half. The safeguarding investigation, which was promised to be completed within four weeks (by 8 February 2025), was not completed until June 2025, largely because of the delay in minute production, representing an avoidable four‑month delay that caused further distress to Mr B.
The Ombudsman also found fault in the Council’s complaint handling: its failure to explain that Adult Social Care complaints follow a one‑stage process led to unnecessary time and trouble for Mr B in seeking a stage two review, and the Council then took almost six months to send him the final safeguarding report after summarising it in the complaint response. That delay, which remained largely unexplained and was only weakly justified by reference to staff absence, was “inexcusable”, greatly exacerbated Mr B’s injustice and contributed to his loss of faith in the safeguarding process. The Ombudsman noted structural weakness in both complaints and safeguarding procedures, including a lack of checks to pick up work affected by staff absence and prevent excessive delays.
To remedy the injustice, the Ombudsman recommended that within one month the Council apologise to Mr B and make a symbolic payment of £800, with £300 recognising the impact on Mr C of the handling of the incident and £500 recognising Mr B’s uncertainty and frustration at the repeated delays. The Council must also review Mr C’s risk assessment to ensure it fully reflects risks arising from his conditions and ensure the art therapy agreed in January 2025 is actually provided. Within two months, the Council must review its complaints process to ensure agreed actions are followed through within specified timescales, and review its safeguarding process to ensure investigations are completed within a reasonable timeframe with checks to detect and resolve emerging delays. The Council has agreed to these recommendations and must provide evidence to the Ombudsman that it has complied.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
This case underlines how fragile trust becomes when safeguarding and complaints processes drift, even after a Council has accepted fault. It shows that delay, poor reasoning and weak communication can be as damaging to people as the original incident, particularly where a vulnerable adult and a family carer are already under strain.
The Council’s first decision that the safeguarding threshold had not been met turned almost entirely on the unexpected nature of Mr C’s behaviour, rather than on what staff actually did and failed to do. On any sensible application of community care law, that approach sits uneasily with a statutory focus on risk, prevention of abuse and neglect, and the duty to consider likely recurrence and wider impact on wellbeing, not just how surprising an incident was in the moment.
At the same time, the Council did eventually recognise that the threshold was met and commissioned a fuller enquiry which accepted there had been significant practice failures by both transport staff and the way information was shared with the police. This later response shows that, when properly directed, internal safeguarding processes can reach more robust findings and lead to concrete learning, training and procedural change.
The report does not identify what the Council meant by the ‘threshold’ for safeguarding. There is a statutory trigger for an investigation turning upon risk of abuse or neglect. There was evidence of neglect here, even if it was not culpable. There is no threshold of significant harm.
For people using services and carers, the complaint illustrates the importance of insisting on written decisions and timescales at each stage, and of challenging speculative reasoning – for example, where a council decides, without evidence, that a failure to share critical health information with the police “would not have made any difference”. Under community care law, such assertions must be grounded in evidence, not assumption, particularly where they go to the heart of whether risk was properly managed.
For councils and practitioners, a key lesson is that “learning lessons” must start at the point of first triage, not months later when complaints escalate. If a council has already identified unsafe practice – such as leaving a non‑verbal autistic adult alone in a vehicle on a busy road, and failing to use any de‑escalation techniques – it is difficult to justify treating the situation as below the safeguarding threshold or to rely on prevention work alone without a formal enquiry. Public law requires that decisions about whether to investigate via safeguarding enquiries are rational, evidence‑based and consistent with the statutory framework on wellbeing and protection.
The Council initially decided that there was no abuse or neglect because Mr C’s behaviour was sudden, staff were familiar with him, there had been no prior concerns, and the bruising was attributed to police attempts to manage immediate risk. That reasoning reads as if the only relevant question was whether staff meant to do harm or could have predicted the incident. Community care law, and public law more broadly, requires a more structured focus on risk, foreseeability and the nature of care relationships. On any view, leaving a non‑verbal autistic adult alone in a vehicle on a busy road, without any attempt at de‑escalation and without equipping police with essential information about his condition, is a serious departure from safe practice. A lawful safeguarding threshold decision therefore had to engage explicitly with whether these omissions amounted to neglect or ill‑treatment in context, rather than treating them as unfortunate but non‑safeguarding “faults” to be tidied up by training. Public law principles require the decision‑maker to address the key relevant considerations; here, that included the extent to which commissioned staff had assumed risks beyond what Mr C or his father could possibly manage.
The second issue is the boundary between prevention and formal investigation. The Council’s first response was to conclude that the safeguarding threshold was not met and to offer risk‑prevention work and future support instead. The Ombudsman criticises the internal logic of this but does not fully explore the legal significance of substituting prevention for investigation where there are already clear indications of unsafe care. There is a distinction between prevention under section 2 and the duty to assess, determine eligibility and meet needs once an appearance of need exists. In the safeguarding context, the same logic applies: where a person with a disability has already experienced serious distress, restraint and injury in the course of commissioned care, prevention cannot lawfully be used as a way of avoiding, or indefinitely deferring, the statutory obligation to enquire into suspected abuse or neglect. In Mr C’s case, once the transport investigation identified unsafe behaviours, the legal test for whether a safeguarding enquiry was required should have been applied against those findings, not against the Council’s view of how surprising the behaviour was.
The third issue is procedural fairness and timeliness in the way the Council handled the MDT minutes, the safeguarding report and the complaint pathway. The Ombudsman rightly labels the delays “inexcusable” and notes structural weaknesses, but the decision stops short of spelling out how far this strays from basic public law requirements. In the public law overview, it is emphasised that public bodies must act fairly, give reasons where the framework demands it, and avoid fettering their discretion or allowing decisions to drift for so long that rights become meaningless in practice. A safeguarding enquiry that is promised within four weeks but takes four months, coupled with minutes that arrive three months late and a final report almost six months after being promised, sits poorly with the duty to conduct Care Act functions within a reasonable time and to maintain public confidence in statutory processes. Moreover, the use of an AI transcription system that failed, followed by an unexplained delay in reconstruction, shows a lack of contingency planning for core governance tasks. Under community care law, these are not mere administrative irritants; they go to whether the Council is discharging its duties in a way that is rational, fair and proportionate, particularly where delays exacerbate the anxiety and uncertainty of a family who have already experienced a serious incident.
In addition, the Council’s handling of complaints illustrates a further, more subtle gap between the legal theory and the Ombudsman’s account. The failure to tell Mr B at stage one that adult social care complaints are subject to a one‑stage process led him to invest time and emotional energy in seeking a stage two that did not exist. Individuals must be given clear, accurate information about routes of redress. Monitoring Officers and complaints systems are vital safeguards against illegality or systemic failure. In this context, mis‑directing a complainant about the structure of the complaints process risks undermining their ability to seek timely legal redress, whether through the Ombudsman or the courts. While the Ombudsman’s remedy of an apology, symbolic payment and process review is appropriate at case level, the underlying legal concern is that such misdirection, if repeated across cases, would amount to a systemic failure to provide the “due process” that community care law presupposes.
Although the report does not mention this, we think that Mr B could have considered a police complaint. The report focuses on the fact that the transport staff did not inform the police about Mr C’s health conditions, but it seems to us that the police could and should have asked why Mr C was alone in the back of a van. They should easily have been able to ascertain that Mr C was an adult with support needs, and that ought to have led them to enquire about his health conditions. The fact Mr C sustained bruising shows that this was far from a minor incident, and the police actions could have constituted a serious assault.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s London Borough of Enfield (25 008 604) 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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