14. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen.
Mr E’s complaint
15. Mr E complains the Trust ‘failed to have appropriate procedures in line with a legal requirement to have them, with named officers for investigation, first and foremost, undertaking a strategic review of any safeguarding issues.’ He also says, ‘the Trust had no procedures which they should have had by law … to send a safeguarding concern to Nottingham and to conduct an internal investigation into the issues I raised about the Adult Discharge Team being unaware of their legal duties to report safeguarding concerns.’ He complains the Trust ‘failed to have a Strategic Committee in place to receive the Safeguarding Concerns’, ‘failed to conduct an investigation into the Adult Discharge Team to look at why they did not take safeguarding seriously’, and ‘failed to refer my mothers safeguarding concerns to Nottinghamshire County Council and provide follows up on the investigation in line with statutory Organisational Abuse Complex Case Protocols.’
The Care Act 2014 and relevant guidance
16. We review below the relevant provisions of the Care Act and associated statutory guidance to identify what elements a safeguarding adults policy should include, as relates to the issues Mr E has raised.
17. Section 42 of the Care Act 2014 requires local authorities to make enquiries whenever abuse or neglect are suspected in relation to a vulnerable adult and an enquiry is needed to decide what action to take to protect them. The lead organisation for safeguarding work in each area is the local council with responsibility for social services. See Partners in Care and Health, ‘Safeguarding roles and responsibilities: Safeguarding is everybody’s business’, 23 May 2023 [the Local Government guidance].
18. All organisations have safeguarding duties. Guidance from the Department of Health and Social Care states, ‘In order to achieve these aims, it is necessary to ensure that everyone, both individuals and organisations, are clear about their roles and responsibilities, and create strong multi-agency partnerships that provide timely and effective prevention of and responses to abuse or neglect.’ Department of Health and Social Care, ‘Care and support statutory guidance’, 22 July 2025 [the DHSC statutory guidance], section 14.12. The DHSC statutory guidance goes on to note that the safeguarding principles apply to ‘all sectors and settings,’ including provision of health and care services and healthcare. Section 14.13.
19. The DHSC statutory guidance at section 14.43 states all organisations must have safeguarding policies and procedures in place to ensure effective safeguarding arrangements. Specifically, ‘All organisations must have arrangements in place which set out clearly the processes and the principles for sharing information between each other, with other professionals and the SAB.’ Additionally the guidance states, ‘No professional should assume that someone else will pass on information which they think may be critical to the safety and wellbeing of the adult. If a professional has concerns about the adult’s welfare and believes they are suffering or likely to suffer abuse or neglect, then they should share the information with the local authority and, or, the police if they believe or suspect that a crime has been committed.’
20. The guidance further specifies all organisations should have adult safeguarding policies and procedures which reflect the DHSC statutory guidance. Section 14.52.
21. The DHSC statutory guidance states that safeguarding allegations should be reported to the relevant local authority. The Local Government guidance elaborates, ‘If someone is concerned that a person with care and support needs is experiencing or at risk of abuse or neglect, they should raise a concern with the council responsible for adult social services in their area.’ The DHSC guidance states, ‘Concerns about abuse or neglect must be reported whatever the source of harm is. It is imperative that poor or neglectful care is brought to the immediate attention of managers and responded to swiftly, including ensuring immediate safety and well-being of the adult.’ Section 14.200.
The Trust’s Safeguarding Adults Policy
22. The Trust provided us with a document called Safeguarding Adults at Risk Procedures (the Trust’s policy), which states its effective date was January 2022 and was up for review in January 2025. It appears this policy was in effect at the time Mr E raised his safeguarding concerns.
23. The Trust’s policy states, ‘The Care Act 2014 places safeguarding duties that have a legal effect in relation to all organisations, not just the local authority who retain their responsibility as the lead co-ordinating organisation. All staff are required to act in a timely way to any concerns or suspicions that an adult at risk is being or is at risk of being abused or neglected.’ Section 4.1.
24. Under Section 12, Individual Agency Roles and Responsibilities in Safeguarding Adults at Risk, the policy states, ‘The Care Act 2014 now places the local authority’s leading coordinating role with all relevant organisations on safeguarding adults within its area in primary legislation for the first time. […] Section 42 of the Care Act 2014 places a statutory duty on local authorities to make enquiries, or ensure others do so, if it believes an adult is subject to, or at risk of, abuse or neglect. An enquiry should establish whether any action needs to be taken to stop or prevent abuse or neglect, and if so, by whom.’
25. Under Section 15, Reporting an Allegation of Abuse, the policy states, ‘On becoming aware of an allegation or concern about the safety and welfare of an adult at risk, staff should discuss the concern with their line manager. […]If unsure of whether this is a safeguarding issue, staff should either consult their safeguarding adults team or make a referral stating clearly the concerns. On receipt of the referral the safeguarding adults team and/ or social services will advise the referrer accordingly.’
26. Finally, the policy states in relation to ‘allegations of abuse or concerns about patients that occurred outside of Trust premises and did not involve Trust staff’, staff should complete a safeguarding adults referral form with as much information as possible, and the safeguarding team will work with social services regarding the concern.
27. Additionally, the Trust has provided evidence it has a safeguarding team, with members of staff designated to respond to and refer safeguarding allegations to the appropriate authorities.
Whether the Trust’s policy is in line with legal requirements
28. Mr E complains the Trust has not adopted a policy in line with legal requirements, with Trust staff assigned to undertake review of safeguarding issues. He also says, ‘the Trust had no procedures which they should have had by law … to send a safeguarding concern to Nottingham.’
29. In the first instance, we are satisfied that the Trust has adopted a safeguarding adults policy, as required by the statutory guidance. We have reviewed the elements of the Trust’s policy which relate to referral of allegations of safeguarding issues occurring outside the Trust to determine whether these are in line with the statutory guidance. We have not conducted a wholesale review of the policy and whether all aspects of it are in line with the guidance as this would not be proportionate to the needs of this case.
30. The Trust’s policy lays out procedures for responding to allegations of abuse and neglect and provides descriptions of the roles and responsibilities for safeguarding within the organisation, as set out in the DHSC guidance, section 14.12. These procedures, roles and responsibilities are set out in various places in the policy, including section 12 (Individual Agency Roles and Responsibilities in Safeguarding Adults at Risk) and section 15 (Reporting an Allegation of Abuse). Consistent with the Care Act and guidance, the policy makes clear the primary responsibility for investigating allegations of abuse and neglect sits with the relevant local authority (see section 12), and specifies that all Trust staff have a responsibility to report instances of neglect to ensure this information is passed to the local authority with responsibility for conducting an enquiry, if appropriate. Section 15 specifies procedures for reporting allegations of abuse and documenting what steps the Trust has taken.
31. We conclude the Trust’s policy appropriately lays out procedures for reporting safeguarding concerns to the relevant investigating local authority as required by the Care Act and statutory guidance.
Whether the Trust’s actions were in line with its policy
32. The Trust’s policy states the Care Act places legal duties on all organisations to act on suspicions an adult is at risk of being abused or neglected. Mr E raised concerns to Trust staff regarding his mother’s treatment at a care home in Nottingham. The Trust followed up on the concerns Mr E raised. The discharge team member discussed the concerns raised by Mr E with their line manager, as required by the policy. Additionally, consistent with the Trust’s policy regarding concerns raised about an entity outside of the Trust, the safeguarding lead nurse submitted a referral form to the local authority in Nottinghamshire, who had responsibility for coordinating with all relevant organisations on safeguarding adults within its area.
33. Thus, the Trust responded appropriately to the concerns Mr E raised. Additionally, it was the local authority in Nottinghamshire, not the Trust, who had an obligation to conduct an investigation into the safeguarding concerns.
34. In response to Mr E’s complaint that the Trust failed to conduct an internal investigation into the Adult Discharge Team being unaware of their legal duties to report safeguarding concerns, this was not necessary as the team members did comply with the safeguarding policy, and reported the concerns appropriately.
Conclusion
35. In response to Mr E’s complaint the Trust failed to act on his safeguarding concerns, we consider that the Trust acted in line with its policy. We have seen evidence the Trust referred the allegations to the appropriate agency, as required by law and the Trust’s policy.
36. Mr E also complained the Trust did not have appropriate safeguarding procedures in place in line with legal requirements. As discussed above, the Trust does have a safeguarding policy in place, which appears to comply with requirements laid out in the Care Act and associated guidance.
37. We also see no indication the Trust failed to adequately train its personnel, given the relevant staff appear to have acted in line with the Trust’s policy here. A further investigation into the Trust’s safeguarding training practices would not be proportionate to the needs of the case.
38. Regarding Mr E’s complaint the Trust failed to conduct an investigation into his concerns, as already noted, there is no indication the Trust had a duty to conduct an investigation as this was for the Local Authority to do. Therefore there is no indication of failing in the fact it did not investigate.
39. Again, we are sorry for the circumstances leading Mr E to bring his complaint to us. We recognise his experiences with the Trust have had a significant impact on him. We understand the lack of resolution to his safeguarding concerns about the care home in Nottinghamshire have extended his process of grieving for his mother. We are aware investigations by Nottinghamshire Council and Nottinghamshire Police may be ongoing, and we hope these investigations contribute to resolution of Mr E’s concerns. However with respect to the Trust, we find it acted consistent with its obligations and relevant guidance. We hope we have explained the thorough consideration we have undertaken and our reasons of reaching our decision, and we hope this decision provides Mr E with some assurance about what happened in response to the concerns he raised to the Trust.