Report Date


Case Against

Swansea Council



Case Reference Number



Upheld in whole or in part

Mrs A complained about the care provided by Swansea Council to her late son, Mr B. In particular, she complained that the care plans produced by the Council for Mr B between 2017 and 2018 were inadequate and not reviewed in a timely and effective manner and that inadequate discussion took place between the Council and Mr B regarding the sharing of information with his family. Mr B took his own life on 22 March 2018.

The investigation found that the care plans met the regulatory standard expected of the Council and that a delay in reviewing Mr B’s 2018 plan had not resulted in an adverse outcome in the care provided. This aspect of the complaint was therefore not upheld. In relation to Mrs A’s complaint that inadequate discussion took place with Mr B regarding the sharing of information with his family, the investigation found no evidence that adequate conversations took place about the extent of involvement he wished his family to have in his care. Policies and procedures were not adequately explained, and whilst increased family involvement may not have changed the ultimate outcome for Mr B, the uncertainty created by this failing was an injustice to Mrs A. The Ombudsman upheld this part of the complaint.

The Ombudsman recommended that the Council should apologise to Mrs A for the failings identified and make a redress payment of £250 for the time and trouble of bringing her complaint to his office. He also recommended that the Council provides evidence that it has reviewed the way in which information sharing with family members is discussed and documented, reviewed the information provided to clients and families ensuring that all information is clear and up to date and that it has reviewed its policies and procedures about managing reports of missing residents from supported accommodation.