Ombudsman rules investigating teams need to consider abuse or neglect by an organisation too

A decision by the Local Government & Social Care Ombudsman into a safeguarding investigation conducted by a County Council serves as a reminder of the need for Councils to consider ‘organisational abuse’ as part of their investigation processes.

The Ombudsman’s investigation found North Yorkshire County Council at fault for its ‘inconclusive decision’ – namely, that it could not find one person at fault. The flawed decision was based on criteria which the Ombudsman said was not in line with the law, guidance or its own policy, and did not reflect the findings of its own investigation.

The issues

Mrs X complained about the respite care Mr X received at a care home. She was unhappy with Mr X’s personal care as he had developed blisters on his legs and was diagnosed with cellulitis which required antibiotic treatment. Mrs X believed that daily skin checks would have reduced the likelihood of Mr X developing cellulitis and that delays in collecting his antibiotics compounded this. This prompted a safeguarding alert.

The Council carried out an investigation which highlighted that there had been clear failings to prevent, identify and treat Mr X’s cellulitis but there were no identified persons alleged to have caused harm. It was said that the failings were systemic but the Council could not identify specific individuals at fault and concluded the safeguarding investigation inconclusive.

Mrs X subsequently complained to the LG&SCO.

The ombudsman’s findings

  • The statutory guidance and the Council’s policy and procedures refer to abuse or neglect by a person or organisation. There is no requirement that abuse or neglect must be shown to have been carried out by one named individual for a council’s safeguarding enquiry to reach a conclusive finding about abuse or neglect at an organisational level. Being unable to identify a responsible person did not therefore mean the Council could not reach a conclusive finding.  
  • The Council should have considered whether organisational abuse had occurred based on its investigation findings (that there were failing by the care provider and Mr X came to harm as a result). It did not do so and closed the case despite Mrs X’s concerns
  • While the Council’s policy and procedures “stress the importance of accountability”, the Council’s recording of the outcome as inconclusive is inconsistent with its findings relating to the accountability for the harm Mr X came to. It also failed to give reasons as to why it had reached an inconclusive finding.
  • The Council was at fault for delays in the investigation which added to Mrs X’s distress.

Ombudsman’s recommendations

  • The Council should apologise to Mrs X for the distress due to its flawed decision–making process.
  • The Council should make a new decision about the conclusion of its safeguarding investigation, taking into account the law, guidance and its own policy and whether organisational abuse did occur and whether it should record a different decision or remove the inconclusive decision.
  • Remind staff that abuse or neglect do not have to be carried out by one identified individual to result in a conclusive outcome.


The decision illustrates the importance for councils to identify organisational abuse and not limit enquiries to finding fault with one individual. Often residents in care homes will be cared for by more than one healthcare professional – it will therefore be important to look at the bigger picture when conducting safeguarding investigations.

Do get in touch if your teams require support with conducting investigations.

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