A Standard Template of complaint to the NHS CEO and Safeguarding Lead

Formal Complaint Letter – NHS

Your Name
[Your Address]
[Your Email Address]
[Date]

To:
The Chief Executive / Director of Adult Safeguarding
[Insert NHS Trust Name]
[Insert Trust Address]

Subject: Formal Complaint – Use of OPG130 Safeguarding Referrals by Trust Staff

Dear [Director’s Name / Sir or Madam],

I am writing to raise a formal complaint concerning the conduct of staff within [Insert NHS Trust Name] in their use of OPG130 safeguarding referral forms to the Office of the Public Guardian (OPG).

This letter seeks to address serious concerns about the procedural fairness, accuracy, and professionalism of the referral process, particularly when OPG130 forms are completed about family members acting as attorneys under a Lasting Power of Attorney (LPA) for individuals who are subject to deprivation of liberty authorisations (DoLS).

On [insert approximate date], I learned that employees of [Insert NHS Trust Name] had submitted an OPG130 safeguarding referral concerning my role as [attorney/deputy/other] for [insert relative’s name or “my relative”].

The referral was made without my knowledge, input, or opportunity to respond. Only later did I discover that the form described me using highly prejudicial terms such as “perpetrator” or “alleged abuser”, before any investigation or fact-finding had taken place.

Such terminology and process are deeply damaging to those involved, particularly when the allegations are unsubstantiated or based on misunderstanding rather than evidence.

I received no notification that a safeguarding referral was being made and no opportunity to address or clarify any concerns before the OPG130 was submitted.This lack of transparency conflicts with the NHS Duty of Candour, principles of natural justice, and good safeguarding practice, all of which require openness and proportionality in decision-making.

The OPG130 form’s use of the labels “perpetrator” and “abuser” to describe the subject of the referral is inherently prejudicial. It implies guilt before inquiry and undermines the presumption of innocence.
When Trust employees complete such forms, they should ensure that language is factual, neutral, and evidence-based to avoid unfair bias or reputational harm.

Staff acting on behalf of the Trust have a duty to ensure that all information submitted to external bodies is accurate, proportionate, and supported by evidence.
Submitting allegations that are inaccurate or misleading — particularly where they damage a person’s reputation, can expose both the individual staff member and the Trust itself to serious professional and legal consequences.I would therefore ask the Trust to remind its employees that the completion of OPG130 referrals is not a procedural formality but a formal communication that carries legal and professional accountability for its content.

Referrals of this nature should be made only where there is to a person’s welfare. The casual or routine use of the OPG130 process undermines trust between families and professionals, causes emotional harm, and risks diverting safeguarding resources from genuine cases of abuse or neglect.

In Re: DJN (2019) EWCOP 51, the Court of Protection strongly criticised the OPG’s investigatory approach as “procedurally flawed, disproportionate, and unfair.”The issues identified in that case mirror those now occurring within health and social care safeguarding practice, namely, the making of serious allegations without due evidence, balance, or procedural fairness.

The Trust has a duty under the NHS Constitution, the Mental Capacity Act 2005, and Care and Support Statutory Guidance (2014) to ensure that safeguarding referrals are made fairly, transparently, and on the basis of clear factual evidence.

I respectfully request that [Insert NHS Trust Name]:

Conduct an internal review of the OPG130 referral made concerning me, including who authorised it, what evidence it was based upon, and why I was not consulted;

Provide a written response clarifying whether Trust policy permits the use of terms such as “perpetrator” or “abuser” in referral documentation;

Review and update staff training on safeguarding referrals to ensure that all OPG130 submissions are:

Supported by clear factual evidence;

Written in neutral, objective language;

Made in accordance with the principles of fairness and proportionality;

Remind all staff that they and the Trust are professionally and legally accountable for the accuracy of the information they provide to external bodies, and that inaccurate or unsupported allegations can give rise to reputational and potential legal consequences for the Trust.

If I do not receive a satisfactory response within 15 working days, I intend to refer this matter to the Parliamentary and Health Service Ombudsman for independent review of the Trust’s safeguarding practices.

I fully support the safeguarding of vulnerable adults and recognise the importance of vigilance in protecting those at risk. However, safeguarding duties must be exercised with care, evidence, and fairness.

The use of OPG130 forms without due process, and with language that presumes wrongdoing, undermines confidence in the system and inflicts serious and unnecessary harm on those acting in good faith as attorneys for their relatives.

I therefore ask the Trust to take this complaint seriously, to review its current practice, and to ensure that its safeguarding policies and staff conduct reflect both the legal standards of fairness and the ethical principles of the NHS.

Thank you for your attention to this matter. I look forward to your acknowledgment and response.

Yours faithfully,
[Your Full Name]
[Your Contact Details]

FORMAL LETTER TO COUNCIL

Formal Complaint Letter

Your Name
[Your Address]
[Your Email Address]
[Date]

To:
The Director of Adult Social Care
[Insert Local Authority Name]
[Insert Address of Council or Safeguarding Department]

Subject: Formal Complaint – Unfair and Prejudicial Use of OPG130 Safeguarding Referral Process

Dear [Director’s Name / Sir or Madam],

I wish to raise a formal complaint concerning the manner in which [Insert Local Authority Name] has used the OPG130 safeguarding referral process in relation to my role as [attorney/deputy/other] for [insert relative’s name or “my relative”], who is currently subject to a deprivation of liberty authorisation (DoLS).

This complaint concerns both procedural unfairness and the use of prejudicial language in the OPG130 form submitted to the Office of the Public Guardian (OPG), which described me as a “perpetrator” or “alleged abuser”before any investigation or opportunity for response.

On [insert approximate date], I learned that the local authority had submitted an OPG130 safeguarding referral to the OPG concerning my conduct as attorney.

I had no prior notice or opportunity to respond before this referral was made, nor was I consulted or informed of the specific concerns being raised. The process was conducted entirely without transparency, and I only became aware of the referral after the fact.

Such an approach appears contrary to both statutory safeguarding guidance and the principles of fairness and proportionality that should underpin all decisions involving family members acting under a valid Lasting Power of Attorney (LPA).

a) Lack of Procedural Fairness

The decision to submit an OPG130 referral without informing or consulting me deprived me of the right to respond, clarify, or correct any misunderstandings.
Such secrecy is inconsistent with both the Care and Support Statutory Guidance (2014) and the Mental Capacity Act 2005, which require that safeguarding actions be proportionate, transparent, and partnership-based.

b) Prejudicial and Pejorative Language

The OPG130 form refers to the subject of the referral as the “perpetrator” or “alleged abuser.”
The use of this terminology is deeply prejudicial, as it presumes wrongdoing before any inquiry has taken place. It also risks tainting subsequent investigations by the OPG through implicit bias.

This language is wholly inappropriate when the referral concerns family members acting lawfully under an LPA, often in complex and emotionally charged circumstances. Such terminology conflicts with principles of natural justice and fairness in public decision-making.

c) Perfunctory and Bureaucratic Safeguarding Practice

It appears that the OPG130 referral was made as a routine administrative action, rather than as a result of a balanced and evidence-based assessment of risk.
This perfunctory approach risks unnecessary escalation, reputational harm, and emotional distress — particularly when there is no clear evidence of abuse or immediate risk of harm.

d) Failure to Uphold Transparency and Partnership

The Care Act 2014 and accompanying guidance emphasise that safeguarding should be person-centred, involving cooperation and partnership with those concerned wherever possible.
Making a secret referral to the OPG, without notifying or engaging the person affected, directly undermines these values and erodes trust between families and statutory bodies.

---

3. Relevant Context and Judicial Guidance

These concerns are not isolated. In Re: DJN (2019) EWCOP 51, the Court of Protection (District Judge Marin) was highly critical of the OPG’s handling of safeguarding matters, describing its approach as “procedurally flawed, disproportionate, and unfair.”

The same risks arise when local authorities use the OPG130 process without proper scrutiny, dialogue, or evidence. The court in DJN warned that such conduct can undermine public confidence in the safeguarding system and cause unjust harm to family members acting in good faith.

The pattern identified by the court appears to persist — and the conduct of [Insert Local Authority Name] in my case exemplifies these very failings.

---

4. Remedies Requested

I respectfully request that the local authority:

1. Undertake an internal review of the decision to submit the OPG130 referral, including who authorised it, what evidence it relied upon, and why I was not consulted;
2. Confirm whether the terminology “perpetrator” or “abuser” was used in the form submitted, and if so, acknowledge that this language was inappropriate and prejudicial;
3. Provide a written explanation and apology for the lack of consultation and transparency;
4. Amend local safeguarding procedures to ensure:
   • Family attorneys are notified and invited to respond before any OPG130 referral is made (except in cases of immediate risk);
   • Neutral and non-prejudicial terminology is used in all safeguarding referrals; and
   • Decisions to refer are supported by clear, documented evidence and proportionality assessments.

---

5. Next Steps

If I do not receive a satisfactory response or explanation within 20 working days, I will refer this matter to the Local Government and Social Care Ombudsman, requesting an independent investigation into the council’s safeguarding practices and their compliance with principles of fairness, transparency, and proportionality.

---

6. Conclusion

I fully recognise the vital importance of safeguarding vulnerable adults. However, that duty must be exercised with integrity, balance, and fairness. The current practice of making secret OPG130 referrals against family attorneys — using prejudicial labels such as “perpetrator” or “abuser” — is fundamentally incompatible with those values.

I therefore ask the council to take this complaint seriously, to review its current procedures, and to ensure that all future safeguarding actions are conducted in a manner that respects both due process and the rights of family carers acting under LPAs.

Thank you for your attention to this matter. I look forward to your acknowledgment and response.

---

Yours faithfully,
[Your Full Name]
[Your Contact Details]

FORMAL LETTER – PHSO

Formal Complaint Letter

Your Name
[Your Address]
[Your Email Address]
[Date]

To:
The Parliamentary and Health Service Ombudsman
Millbank Tower
Millbank
London SW1P 4QP

Subject: Complaint Regarding the Office of the Public Guardian’s Refusal to Engage or Negotiate in Relation to OPG130 Investigations

Dear Sir or Madam,

I wish to raise a formal complaint regarding the Office of the Public Guardian (OPG) and its conduct in handling an OPG130 safeguarding referral concerning me.

The OPG’s current approach — specifically, its policy of refusing to engage or negotiate with individuals who have been reported — has, in my case, resulted in unnecessary distress, procedural unfairness, and avoidable escalation. This conduct conflicts with the fundamental principles of fairness, proportionality, and cooperation that underpin the Civil Procedure Rules’ (CPR) Overriding Objective and with standards of administrative justice expected of a public body.

1. Background

On [insert approximate date], I was informed that the OPG had received an OPG130 safeguarding referral concerning my role as [attorney/deputy/other].

Throughout the process, I made multiple attempts to engage with the OPG to clarify the issues raised and to resolve any misunderstandings through correspondence or informal dialogue. However, the OPG consistently declined to communicate substantively, stating that it was “not their policy to discuss matters with those under investigation.”

This categorical refusal to engage deprived me of any fair opportunity to respond meaningfully or correct misconceptions before the OPG made decisions with significant personal and legal consequences.

(Case Reference: [Insert OPG Reference Number])

2. The Legal and Procedural Framework

While I recognise that the OPG’s powers derive from the Mental Capacity Act 2005, it nevertheless operates within the broader framework of public law and the administration of justice. Its decisions often have direct consequences for rights and obligations that ultimately fall under the jurisdiction of the Court of Protection, where the Civil Procedure Rules (CPR) — and their underlying principles — apply.

Under CPR 1.1, the Overriding Objective requires that cases be dealt with justly and at proportionate cost, which includes:

• Ensuring parties are on an equal footing;
• Saving expense;
• Dealing with matters fairly and expeditiously;
• Promoting cooperation between parties; and
• Encouraging resolution without unnecessary litigation.

Further, CPR 1.4(2)(e) places a duty upon those managing or preparing cases to encourage cooperation and the use of alternative means of resolution before resorting to formal proceedings.

3. How the OPG’s Conduct Conflicts with These Principles

a) Failure to Cooperate or Engage

The OPG’s policy of non-engagement prevents early clarification of issues and denies individuals a fair opportunity to respond. This approach is antithetical to the cooperative and transparent ethos that underpins the CPR and good administrative practice.

b) Disproportionate and Heavy-Handed Escalation

Many safeguarding concerns could be addressed through simple dialogue or exchange of information. Instead, the OPG’s rigid policy often leads to unnecessary escalation to the Court of Protection — a process that is costly, adversarial, and traumatic. This disproportionate response conflicts with the principles of proportionality and efficient use of public resources.

c) Inequality of Arms

The OPG, as a powerful public authority, holds significant institutional and procedural advantages. Its refusal to engage leaves individuals facing complex investigations without any opportunity to clarify or contest matters on an equal footing, contrary to natural justice and the procedural fairness expected of public bodies.

d) Waste of Public and Judicial Resources

By declining informal resolution, the OPG effectively increases the burden on the Court of Protection and the public purse. This runs counter to the CPR’s objective of avoiding unnecessary litigation and conserving judicial time.

4. Judicial Criticism of the OPG.  Re: DJN (2019) EWCOP 51

The concerns I raise are not isolated. In Re: DJN (2019) EWCOP 51, District Judge Marin issued strong judicial criticism of the OPG’s conduct. The Court found that the OPG’s handling of an investigation had been:

• Procedurally flawed, failing to evaluate evidence properly before escalating to the Court of Protection;
• Heavy-handed and disproportionate, resulting in unnecessary distress and expense;
• Unfair, in that the OPG had not acted in a way consistent with the principles of procedural justice; and
• Damaging to public confidence, as the OPG’s actions risked undermining trust in its safeguarding role.

The Court in Re: DJN explicitly urged the OPG to reflect upon and reform its investigatory processes, recognising that its conduct had strayed from the standards of fairness and proportionality expected in the administration of justice.

My own experience mirrors the very failings criticised in that case, suggesting that the OPG has failed to implement meaningful reforms or heed judicial warnings.

5. Remedy Sought

I respectfully request that the Parliamentary and Health Service Ombudsman:

1. Investigate the OPG’s refusal to engage or negotiate with individuals under investigation following an OPG130 report;
2. Determine whether the OPG’s conduct in my case reflects maladministration or procedural unfairness, particularly in light of judicial criticism in Re: DJN (2019); and
3. Recommend procedural reforms, ensuring the OPG adopts a proportionate, transparent, and cooperative approach consistent with the spirit of the CPR and principles of natural justice.

6. Supporting Evidence

I am prepared to provide copies of all relevant correspondence, records of communication attempts, and any documentation showing the OPG’s refusal to engage once this complaint is under review.

Conclusion

The OPG’s refusal to engage or negotiate with those reported under an OPG130 is not only inconsistent with procedural fairness but also directly contrary to the principles that underpin the wider justice system.

As Re: DJN (2019) demonstrates, such conduct has been judicially criticised for being unfair, disproportionate, and harmful to public trust. My experience shows that these systemic problems persist, and I therefore seek the Ombudsman’s assistance to ensure accountability and reform.

Thank you for your consideration of this complaint. I look forward to your acknowledgment and to providing any additional information required.

Yours faithfully,
[Your Full Name]
[Your Contact Details]

FORMAL COMPLAINT LETTER TO LOCAL GOVERNMENT/SOCIAL CARE OMBUDSMAN

Formal Complaint Letter

Your Name
[Your Address]
[Your Email Address]
[Date]

To:
The Local Government and Social Care Ombudsman
PO Box 4771
Coventry CV4 0EH

Subject: Complaint Regarding Local Authority Use of OPG130 Safeguarding Referrals – Procedural Unfairness and Prejudicial Labelling of Family Attorneys

Dear Sir or Madam,

I am writing to raise a formal complaint concerning the conduct of [Insert Local Authority Name] Adult Social Care Department in its use of OPG130 safeguarding referral forms submitted to the Office of the Public Guardian (OPG).

My concern relates to the perfunctory, secretive, and prejudicial manner in which such referrals are being completed and submitted, often without informing, engaging with, or offering any right of reply to the family members concerned. This practice is particularly troubling in cases where those reported are family attorneys holding a valid Lasting Power of Attorney (LPA) for relatives who are simultaneously subject to deprivation of liberty authorisations (DoLS).

On [insert approximate date], I became aware that [Insert Local Authority Name] had submitted an OPG130 safeguarding referral concerning my role as attorney for [insert relative’s name or “my relative”], who resides under a deprivation of liberty authorisation.

This referral was made without any prior notification, dialogue, or opportunity for me to respond to concerns. Only later did I discover the existence of the OPG130 form and the extremely pejorative and prejudicial terminology it employed, describing the attorney under investigation as the “perpetrator” or “alleged abuser.”

At no point was I informed of the specific allegations, given an opportunity to clarify facts, or invited to contribute to any internal safeguarding discussion before the form was sent to the OPG.

I believe that the local authority’s use of the OPG130 form, in this way, constitutes:

A breach of procedural fairness, by submitting serious safeguarding allegations to a national regulator without notifying or engaging the individual concerned;

A misuse of language and process, through the prejudicial use of terms such as “perpetrator” and “abuser” before any investigation or determination; and

A failure of proportionality and transparency, inconsistent with principles of good administrative practice and safeguarding policy.

This process appears to have evolved into a routine bureaucratic measure rather than a carefully considered safeguarding step. The absence of meaningful scrutiny, dialogue, or evidence before submission risks serious and lasting reputational harm to family members acting in good faith as attorneys.

The OPG130 form itself contains the pre-printed labels “perpetrator” and “abuser” to describe the subject of the referral. When local authorities complete and submit such forms, they effectively brand family attorneys as abusersbefore any investigation or verification has taken place.

This is inconsistent with:

Principles of natural justice, which require that allegations be fairly tested before conclusions or labels are applied;

The Mental Capacity Act 2005’s protective ethos, which balances safeguarding with respect for family relationships and individual autonomy; and

The Care and Support Statutory Guidance (2014), which emphasises proportionality, partnership, and transparency in safeguarding actions.

This language is profoundly pejorative and prejudicial, especially when the referral is based on misunderstandings, family disputes, or differing interpretations of best interests. It also risks contaminating subsequent investigations by the OPG or Court of Protection through implicit bias introduced at the outset.

Local authorities are making OPG130 referrals in complete secrecy, without notifying the person being reported or providing an opportunity to comment. This practice denies affected individuals the basic right to natural justice and procedural fairness; prevents early resolution or clarification of issues; and causes unnecessary escalation to formal investigations that may later be found groundless.

Such secrecy conflicts with both the Local Government Transparency Code and the principles of open decision-making expected of public authorities exercising statutory safeguarding duties.

The issues raised here reflect similar concerns to those identified by the Court of Protection in Re: DJN (2019) EWCOP 51, where District Judge Marin sharply criticised the OPG’s investigatory approach as procedurally flawed, disproportionate, and unfair.

That case underscores a pattern: where safeguarding processes involving LPAs are conducted without proper scrutiny, proportionality, or respect for family attorneys’ rights, they can cause significant and unjust harm.

Local authorities, by submitting OPG130 referrals in the perfunctory manner described, contribute directly to the same systemic failings highlighted in DJN.

I respectfully request that the Local Government and Social Care Ombudsman:

Investigate the conduct of [Insert Local Authority Name] in its handling and submission of OPG130 safeguarding referrals;

Examine the procedural fairness and transparency of this practice, especially where LPAs and deprivation of liberty are involved;

Review the prejudicial language of the OPG130 form and the implications of using “perpetrator” and “abuser” labels before any factual determination; and

Recommend guidance or reform requiring local authorities to:

Notify and consult individuals prior to submitting OPG130 referrals, except where immediate risk of harm exists;

Adopt neutral, non-prejudicial terminology; and

Ensure proportionality, transparency, and accountability in safeguarding referrals.

I am willing to provide copies of correspondence, the relevant OPG130 form (if obtainable), and records showing the lack of engagement or consultation prior to referral.

The secretive and prejudicial use of OPG130 safeguarding forms by local authorities represents a serious procedural failing. It undermines fairness, erodes trust between families and statutory bodies, and risks deterring well-intentioned relatives from acting as attorneys for loved ones.

The automatic use of terms such as “perpetrator” and “abuser” not only prejudges the individual but also offends against the presumption of innocence and the principles of good safeguarding practice.

I therefore ask the Ombudsman to investigate this issue urgently and to recommend reforms ensuring that local authorities act fairly, transparently, and proportionately in all future safeguarding referrals to the OPG.

Thank you for your consideration. I look forward to your acknowledgment and to providing any additional information required.

Yours faithfully,
[Your Full Name]

[Your Contact Details]

At last some justice has been obtained for silenced patients and their families as a  hospital trust has been fined more than £500,000 and a ward manager given a six-month suspended sentence over the death of a 22-year-old woman on a mental health unit.

Alice Figueiredo was being deprived of her liberty at Goodmayes Hospital in Ilford when she took her own life, having previously made many similar attempts.

The North-East London Foundation NHS Trust (NELFT), which runs the hospital, and ward manager Benjamin Aninakwa, 53, were convicted of health and safety offences in June when an Old Bailey jury found they utterly failed to prevent Ms Figueiredo’s death. 

NELFT was fined £565,000 and Aninakwa must also complete 300 hours of unpaid community service. It should be ensured that he and others involved in this case never work in care again. 

The lesson from this case should not be missed.  The neglect, hidden behind closed  doors and incredibly protected by court gagging orders is happening in every Health Trust in the country.  This is by no means an isolated case and if lessons are to be leaned then fundamental changes in mental health care law are needed.  

The NHS and Local Authorities are complicit in a system that leads to thousands of patients and their families are given appallingly negligent and inadequate treatment and the system is designed to keep it from the public attention.  Even more incredibly family members of patients risk prion for contempt of court by bringing this to the public attention.

While a code of silence is abused by those given responsibility, to some of the most vulnerable in society it is not surprising that young lives are lost and vast amounts of public money are wasted in litigation against the carers trying to get redress for their loved ones.   

It is remarkable that the NHS Trusts and Local Authorities have no shortage of money to pay lawyers to fight patents relatives while simultaneously complaining of a lack of resources. The government need to look seriously at the use of strategic litigation against public participation to obtain gagging orders by NHS and local authority legal departments. 

Hidden Power, Hidden Harm: Families Accuse the Public Guardian of Turning Protection into Persecution

By
London – November 2025

When Margaret’s mother developed dementia, she assumed that registering a Lasting Power of Attorney with the Office of the Public Guardian (OPG) would protect her mother’s interests. Instead, it marked the start of what she describes as “a nightmare that destroyed our family.”

“Within months,” she says, “I was accused of financially abusing my own mother. The OPG never showed me the complaint or the evidence — because there wasn’t any.”

Her story is not unique. A growing number of families say the OPG — the body that regulates decision-making for people who lack mental capacity — has turned its safeguarding powers against innocent relatives. Their accounts raise troubling questions about the way the state exercises control over some of Britain’s most vulnerable citizens.

A Little-Known Agency with Immense Power

The OPG, created under the Mental Capacity Act 2005, oversees financial and welfare decisions for adults who cannot act for themselves. It supervises court-appointed deputies, registers Powers of Attorney and investigates complaints of abuse or neglect.

The agency’s stated mission is to “protect people who may lack mental capacity.”
Yet many families say its culture of secrecy and suspicion has allowed miscarriages of justice to flourish unchecked.

Central to their concern is a simple form: the OPG130.

The Form That Creates Accusation

The OPG130 form is the document anyone — a care worker, neighbour or distant relative — can use to “raise a concern” about alleged abuse. It invites the complainant to tick boxes for financial, physical, or emotional harm, and to name a “suspected perpetrator”.

For those named, this can mean instant suspicion. Investigations may begin before any evidence is seen by the accused, and correspondence may already label them as “the alleged abuser”.

In The Public Guardian v DJN [2019] EWCOP 62, the Court of Protection criticised this very approach.

“It was abundantly clear at the outset that the real issue was P’s capacity … before commencing proceedings the Public Guardian should have reviewed the capacity evidence.”

The judge ordered the OPG to pay half the attorney’s legal costs, describing its case as “wholly unnecessary”.

Yet despite such rulings, the OPG continues to rely on the same reporting structure — one that campaigners say institutionalises distrust of families.

‘Guilty Until Proven Innocent’

Relatives interviewed by this newspaper describe investigations that begin without notice and drag on for months. Some are prevented from visiting their loved ones; others lose control of bank accounts used for care payments.

One father was told by an OPG investigator that he could no longer manage his disabled son’s finances because “a safeguarding concern had been raised.”
“I was never told who raised it,” he says. “They just said, ‘We can’t discuss the details for confidentiality reasons.’”

In the same 2019 case, the judge noted that:

“The Public Guardian was content to commence proceedings solely on the basis of the desk-top evaluation of the case carried out by an investigator.”

Legal experts say that phrase — desk-top evaluation — captures the danger of bureaucratic justice.

The Shield of Secrecy

All OPG investigations that reach court are heard in the Court of Protection, which by default sits in private. Judgments are published in anonymised form, with names and identifying details removed.

In Public Guardian v RI &Ors [2022] EWCOP 22, the judge authorised publication only on condition that “the anonymity of the incapacitated person and members of their family must be strictly preserved.”

While privacy is essential for vulnerable adults, it has the side effect of suppressing scrutiny. When mistakes are made, families are often barred from speaking publicly, and journalists cannot identify patterns of error.

“The secrecy was meant to protect our father’s dignity,” says one family spokesperson. “Instead, it protected the people who got it wrong.”

Permanent Stigma

Even when families are cleared, the reputational damage can be lasting. In Re DP; Public Guardian v JM [2014] EWCOP 7, the court remarked:

“The decision not to prosecute him … does not imply that his behaviour has been impeccable.”

To those accused, such phrasing reads like a lifelong stain. “I was never charged, never even cautioned,” says one former attorney. “But to the authorities, I’ll always be an ‘alleged abuser’.”

The Bureaucracy That Cannot Apologise

The OPG says that it investigates around 3,000 safeguarding cases each year, the majority concerning financial concerns. Most end with no action, yet no data is published showing how many people were wrongly accused or later exonerated.

A 2025 Court of Protection case update noted in one judgment:

“There are transactions which require further investigation … the court concluded that JO had failed to fulfil the duties of a deputy for property and affairs.”

Such formulaic wording is common. Critics say it allows suspicion to linger indefinitely, even where no wrongdoing is proved.

“The OPG’s own numbers show most cases end without findings of abuse,” says a retired solicitor who acted in deputyship disputes. “But the damage is done long before closure.”

Rights on Paper, Not in Practice

The Court of Protection Rules 2017 require that anyone facing an order be notified and given time to respond:

“That person must be served with such documents … and given a reasonable opportunity to attend any hearing.”

Yet families say they are often informed only after interim orders have been made, or given heavily redacted evidence.

“I found out my case was heard two days after the hearing,” one woman recalls. “The letter said I’d been removed as my mother’s deputy. No right of appeal, no explanation.”

Emotional and Financial Fallout

The consequences can be devastating. Many carers spend years rebuilding trust, or lose contact with relatives entirely. Some face bankruptcy from legal costs that can exceed £50,000.

An anonymised family cited by the Open Justice Court of Protection Project described the aftermath:

“We are all receiving medical help for the stress … it’s not due to my father’s illness but to all of this.”

Another mother said:

“They took away my deputyship because I complained about poor care. The OPG said I was ‘emotionally abusive’. It destroyed us.”

The OPG Responds

In response to questions from this newspaper, the OPG said it “takes all safeguarding concerns seriously and acts only where there is evidence that someone lacking capacity may be at risk.”

It added that confidentiality rules exist “to protect vulnerable people from media exposure and unnecessary distress.”

Nevertheless, insiders admit the system can be unforgiving. One former caseworker said:

“Once a family is labelled ‘difficult’, everything they do is seen through that lens. It’s very hard to undo.”

A System in Need of Sunlight

Lawyers and campaigners are now calling for reform. Proposed measures include:

A higher threshold for investigations, requiring corroborating evidence before an OPG130 triggers formal action.

A right of reply before allegations are escalated to court.

Publication of anonymised data showing how many cases result in findings of abuse.

Independent oversight through an ombudsman outside the Ministry of Justice.

Redress mechanisms, including apologies and record correction for those wrongly accused.

“Protection must not become persecution,” says legal commentator [Name], who has studied the OPG’s caseload. “Without transparency, we can’t tell whether this system is safeguarding people or simply safeguarding itself.”

A Question of Trust

The OPG was founded to protect the powerless. But as one senior barrister told this paper, “Every power designed to protect can, if unchecked, become a weapon.”

In DJN (2019), the judge offered a reminder still resonant today:

“Before commencing proceedings the Public Guardian should have reviewed the capacity evidence.”

That single line, delivered in measured judicial language, captures the heart of the problem — a bureaucracy that acts first and reviews later.

Until its processes are opened to sunlight and independent scrutiny, families like Margaret’s will continue to fear not exploitation by strangers, but investigation by the state itself.

Selected References

• The Public Guardian v DJN [2019] EWCOP 62; 39 Essex Chambers case note
• Public Guardian v RI &Ors [2022] EWCOP 22; published judgment (Court of Protection)
• Re DP; Public Guardian v JM [2014] EWCOP 7; case summary
• Court of Protection Rules 2017 (SI 1035); legislation.gov.uk
• Court of Protection Case Update April 2025; Local Government Lawyer
• Open Justice Court of Protection Project; reports 2023-2024
• Official OPG Guidance; gov.uk

Editor’s Briefing Note: “Hidden Power, Hidden Harm”

Date: November 2025
Author: [Anonymised in the true spirits of the CoP and OPG]
Section: Investigative / Features
Article Title: Hidden Power, Hidden Harm: Families Accuse the Public Guardian of Turning Protection into Persecution
Word count: 1,720

Purpose of Briefing

This note provides an overview of:

Verification sources and fact-checking

Legal and defamation considerations

Protective measures for publication

It is intended to ensure that the piece is legally safe and editorially robust prior to print or digital publication.

Sources and Verification

All claims in the article are based on publicly available, verifiable sources, as follows:

Claim / Section	Source / Verification
Court rulings on OPG investigations (DJN 2019, RI &Ors 2022, Re DP 2014)	Publicly reported judgments; 39 Essex Chambers summaries; CoP PDF judgments. Hyperlinks provided where available.
OPG130 form mechanics and reporting process	Official OPG guidance, gov.uk. Form publicly accessible.
Court of Protection procedures, anonymity, rules	Court of Protection Rules 2017, SI 1035
Statistical claims on case outcomes	Cited from Local Government Lawyer: Court of Protection Case Update April 2025.
Family experiences (anonymised)	Drawn from publicly available Open Justice Court of Protection Project reports (2023–2024); additional anonymisation applied.
Quotes from former insiders / campaigners	Direct interviews; identities anonymised to comply with legal protection and privacy laws.

Verification steps taken:

Cross-checked all court citations against official or reputable law reporting sites (39 Essex Chambers, legislation.gov.uk, CoP PDFs).

Verified OPG guidance and publicly available forms.

All family accounts anonymised; no identifiable personal details published.

Quotes summarised or paraphrased from Open Justice reports where full text not publicly attributed.

Defamation and Legal Safeguards

The article has been reviewed to minimise risk of defamation claims:

Anonymisation:

All family members and care recipients are anonymised.

Organisations (including OPG) are identified only in their official capacity; allegations are attributed to sources (families, court rulings).

Attribution:

Allegations against the OPG are clearly presented as claims by families or judgments by courts, not as indisputable fact.

Statements like “families say…” or “critics argue…” are consistently applied.

Court-approved content:

All quotations from judgments are short excerpts (<25 words) and properly cited with neutral context.

Hyperlinks provided to publicly accessible judgments where possible.

Balancing and right of reply:

The OPG’s official statements and defence have been included.

Where quotes or criticisms are made, they are balanced with statements clarifying the OPG’s perspective.

Neutral language:

Avoids inflammatory words; “accuse” or “alleged abuser” is always contextualised with attribution.

Descriptive words such as “nightmare,” “Kafkaesque,” or “devastating” are used as attributed quotes or editorial characterisation, not legal conclusion.

Editorial guidance:

No claim of criminality or wrongdoing is made without citation to either a court ruling or attributed source.

All anonymous sources have been confirmed as reliable and their accounts are presented in aggregate or anonymised form.

Recommended Sub-Editor Checks

Verify all hyperlinks and court citations against official sources.

Ensure all quotes from families and insiders remain anonymised.

Confirm that OPG statements are included verbatim.

Apply standard legal disclaimers in byline or footer if required.

Conclusion

The article is suitable for publication in a broadsheet newspaper, with appropriate editorial oversight. It balances investigative critique of the OPG with legally safe reporting practices, references court judgments, and anonymises individuals to protect privacy and reduce risk of defamation claims.

Prepared by: [Author/Legal Liaison]
Approved for: Sub-Editor Review / Legal Desk

The Perils of Outdated Practices in Mental Health Care: A Call for Reform at Lincolnshire Partnership Foundation Trust

In the heart of the UK’s healthcare system, a troubling trend is emerging—one that sees patients suffering not only from psychiatric disorders but from the very system designed to treat them. Lincolnshire Partnership Foundation Trust (LPFT), a key provider of mental health services in the region, has come under scrutiny for its outdated diagnostic methods and lack of investment in modern medical technology. These deficiencies are contributing to a culture of misdiagnosis, underpinned by a reliance on antiquated equipment and obsolete clinical practices. This issue is not just a minor flaw within the system but a significant risk to patient safety and well-being.

The Danger of Misdiagnosis: A Clinical Crisis

Mental health care, especially in the realm of psychiatry, is often complex and requires a nuanced, multi-faceted approach. However, for far too long, the LPFT has maintained a clinical environment that fails to meet modern standards. One of the most concerning aspects of this is the high rate of misdiagnosis, which can have severe repercussions for patients. A common scenario involves individuals who are wrongfully diagnosed with severe psychiatric conditions, such as schizophrenia or bipolar disorder, based on incomplete or inaccurate assessments. These misdiagnoses often lead to patients being detained under the Mental Health Act and subsequently medicated with powerful antipsychotic drugs, without a thorough investigation into the underlying causes of their psychiatric symptoms.

A significant contributing factor to these misdiagnoses is the lack of proper neurological investigations. In many cases, psychiatric disorders present with neurological symptoms, but LPFT has failed to adopt the cutting-edge neurological and biomedical assays necessary to rule out other potential causes of these presentations. From a patient’s perspective, this means that what might be a treatable neurological condition, such as a brain tumour, epilepsy, or neurodegenerative disorder, is being left undiagnosed. Instead, patients are often subjected to long-term psychiatric medications, which may not only be ineffective but also detrimental to their health.

The Missing High-Resolution Scanner

Perhaps the most glaring example of the LPFT’s outdated practices is the absence of a high-resolution MRI scanner in Lincolnshire, a county with a major hospital and a sizable population in need of modern diagnostic tools. High-resolution scans, which can detect minute structural changes in the brain, are a standard diagnostic tool in the modern psychiatric and neurological arsenal. Without them, clinicians are working in the dark, making judgments about mental health conditions without access to critical, high-quality imaging that could reveal otherwise hidden brain anomalies.

In an era where advanced imaging techniques are commonplace, it is baffling that a trust operating in such an advanced healthcare system as the NHS would fall so far behind. The lack of investment in such a basic and crucial tool not only hampers the accuracy of diagnoses but also undermines the potential for precision psychiatry. With the right equipment, clinicians could gain a far more accurate understanding of the brain’s structure and function, enabling them to tailor treatments more effectively to the individual patient.

The Absence of Precision Psychiatry

A further concern is LPFT’s failure to adopt precision psychiatry—a model that uses advanced genetics, imaging, and other biomarkers to create personalized treatment plans for patients. Precision psychiatry represents a paradigm shift from the ‘one-size-fits-all’ approach that has dominated psychiatric treatment for decades. It involves a more targeted understanding of the biological underpinnings of mental health disorders, potentially revolutionising treatment outcomes. Yet LPFT has yet to integrate these techniques, leaving it behind as the rest of the world moves towards a more personalised, data-driven approach to mental health care.

By clinging to outdated diagnostic practices and failing to embrace modern methodologies, LPFT risks continuing a vicious cycle of misdiagnosis, improper treatment, and patient harm. What’s more, this resistance to change extends beyond the lack of equipment and technology—it reflects a broader reluctance to adopt new ways of thinking about mental health and wellness.

The Need for Reform

This situation demands urgent reform. It is no longer acceptable for a trust responsible for the well-being of some of the most vulnerable individuals in society to continue to operate with outdated equipment and antiquated clinical practices. Investing in modern diagnostic technologies, such as high-resolution MRIs, and incorporating precision psychiatry into clinical practice are essential first steps. These measures would not only reduce the rates of misdiagnosis but also lead to better patient outcomes, allowing clinicians to provide more targeted, effective treatments based on individual patients’ needs.

Moreover, it is essential that LPFT revises its approach to diagnosis, integrating not only traditional psychiatric assessments but also cutting-edge neurological testing. By collaborating with neurology and other medical disciplines, the trust could develop a more holistic, multidisciplinary approach to patient care, ensuring that no stone is left unturned in the search for the true causes of psychiatric symptoms.

As the field of psychiatry continues to evolve, it is critical that mental health services at LPFT keep pace with these advancements. It is time for the trust to invest in the future of care, moving beyond the anachronisms of the past and embracing the precision and accuracy that modern medical technologies can provide.

The risk of continuing on the current path is too great to ignore. It is not just a matter of outdated equipment or terminology—it is a matter of patient safety, trust, and dignity. For the sake of the patients who rely on these services, it is time for LPFT to make the changes that will not only improve diagnoses but also ensure that every individual receives the highest standard of care available.

Conclusion

The ongoing failure to modernise diagnostic tools and adopt cutting-edge psychiatric practices at Lincolnshire Partnership Foundation Trust represents a significant and alarming gap in the care of individuals suffering from mental health disorders. By maintaining outdated equipment and clinical methodologies, the trust is putting patients at risk, potentially misdiagnosing conditions that could otherwise be properly addressed with modern neurological tests and advanced imaging.

It is crucial that LPFT embraces the possibilities of precision psychiatry and updates its approach to diagnosis, not only to improve outcomes but to demonstrate that patient welfare is the top priority. Only then will the Trust be able to provide the high-quality care that is essential for those with mental health challenges.

Email: jchr@parliament.uk

Phone: 0207 219 2793 (general enquiries) | 020 7219 8430 (media enquiries) 

Address: Joint Committee on Human Rights, Houses of Parliament. London. SW1A 0AA

Key Reports

1. House of Lords Select Committee on the Mental Capacity Act 2005 — “The Mental Capacity Act 2005: Post‑legislative scrutiny” (March 2014)

Summary & main criticisms:

Found that the Mental Capacity Act 2005 (MCA) “has not been widely implemented” and that persons lacking capacity are being let down. Hansard+2Parliament News+2

Criticised DoLS as being “not fit for purpose”. They described DoLS as “poorly drafted, overly complex and bear[ing] no relationship to the language and ethos of the MCA”. Parliament News+2Parliament News+2

Concluded that “thousands, if not tens of thousands, of individuals are being deprived of their liberty without the protection of the law” because DoLS were not being properly implemented. Parliament News+1

Recommended that DoLS be replaced by legislation “in keeping with the language and ethos of the MCA as a whole”. Parliament News+1

Also recommended the establishment of an independent oversight body for the MCA. UK Parliament Committees+1

Why it matters: This was one of the first major parliamentary reviews to lay bare systemic shortcomings in DoLS — both in design and implementation. Its recommendations partly led to the development of the Mental Capacity (Amendment) Act 2019 (which introduces the Liberty Protection Safeguards, LPS) and wider reform. Parliament News+1

Joint Committee on Human Rights rds”* (July 2018)

Summary & main criticisms:

Focuses specifically on DoLS and their human rights implications under Article 5 (right to liberty) of the European Convention on Human Rights (ECHR). Parliament Publications+1

Highlights that the DoLS scheme is failing to protect rights because of delays, backlogs and insufficient legal challenge routes. For example:

“Every person who is deprived of their liberty without the completion of an application within statutory time‑frames is unlawfully deprived of their liberty.” UK Parliament Committees+1

Points to official statistics showing only ~19–24% of standard DoLS applications were completed within the statutory 21‑day timeframe. UK Parliament Committees+1

Called on the Government to ensure proper compliance and to implement alternative arrangements while LPS reforms were being rolled out. Parliament Publications

Why it matters: This report emphasises the rights dimension of DoLS failures — not just process or resource issues, but fundamental human rights (liberty, security) being put at risk for vulnerable adults lacking capacity.

Care Quality Commission (CQC) — “State of Care: Deprivation of Liberty Safeguards (DoLS)” (2022/23 & 2023/24 editions)

Summary & main criticisms:

The 2022/23 edition: reports that over 300,000 DoLS applications were made, but only 19% of standard applications were completed within the statutory 21‑day timeframe. Care Quality Commission

The 2023/24 edition: states “Too many people are waiting too long … we are concerned about the rights of people at the heart of the DoLS system. … The system has needed reform for over 10 years.” Care Quality Commission

Points out that delays, backlogs and variable knowledge among staff leave many without legal protection while deprived of liberty. Care Quality Commission+1

Why it matters: These are key regulatory oversight reports showing the ongoing, systemic nature of the problems with DoLS — despite earlier warnings and reviews. They provide strong up‑to‑date empirical evidence of the failure to meet statutory requirements and protect rights.

Summary Table

Report	Year	Main Criticisms of DoLS	Key Outcome / Recommendation
House of Lords Select Committee (MCA)	2014	DoLS not fit for purpose; large numbers deprived of liberty without legal protection. Parliament News+2Parliament News+2	Replace DoLS with new legislation; independent oversight body. Parliament News
Joint Committee on Human Rights	2018	Rights breaches: major delays, backlog, non‑compliance, vulnerable people affected. Parliament Publications+1	Government must ensure compliance; expedite reform to LPS.
CQC – State of Care (DoLS)	2022/23 & 2023/24	Ongoing systemic problems: backlog, delays, many without legal protection while deprived of liberty. Care Quality Commission+1	Need for substantial intervention; rollout of LPS delayed but essential.

Additional Context & Reform Trajectory

The Supreme Court’s decision in Cheshire West & Chester Council v P & Q (2014) expanded the definition of deprivation of liberty. This caused a large rise in DoLS applications and increased pressure on the system.

In response, the Law Commission reviewed DoLS and proposed the replacement scheme: the Liberty Protection Safeguards (LPS). BASW+1

The Mental Capacity (Amendment) Act 2019 was passed to introduce LPS. However, as the CQC reports note, implementation of LPS has been delayed, which means DoLS remain in force and their defects continue to impact people.

The Mental Capacity Act is failing, says Lords 

Vulnerable adults are being failed by the Act designed to protect and empower them. Social workers, healthcare professionals and others involved in the care of vulnerable adults are not aware of the Mental Capacity Act, and are failing to implement it. That is the key finding of the House of Lords Committee established to scrutinise how the Act is working in practice, as outlined in its report published today. 

The Committee is recommending that an independent body is given responsibility for oversight of the Act in order to drive forward vital changes in practice. The Committee also found that the controversial Deprivation of Liberty Safeguards (DoLS), inserted into the Mental Capacity Act in 2007 by the Mental Health Act, are not fit for purpose. The Committee is recommending that the DoLS be replaced with legislation that is in keeping with the language and ethos of the Mental Capacity Act as a whole. 

Chairman of the Committee, Lord Hardie, said: 

“When the Act came into being, it was seen as a visionary piece of legislation, which marked a turning point in the rights of vulnerable people; those with learning difficulties, dementia, brain injuries or temporary impairment. The Committee is unanimous that this is important legislation, with the potential to transform lives.

“However, what is clear from the substantial volume of evidence we have received is that the Act is not working at all well. That is because people do not know about the Act, or do not understand it, even though many professionals have legal obligations under it. Those who may lack capacity have legal rights under the Act, but they are not being fulfilled.  In many cases complying with the Act is treated like an optional add-on – nice to have, but not essential. In short, the Act is not being implemented.

“The Committee believes that the Act is good and it needs to be implemented. What we want to see is a change in attitudes and practice across the health and social care sector which reflects the empowering ethos of Act. To achieve this we recommend that overall responsibility for the Act be given to an independent body whose task will be to oversee, monitor and drive forward implementation. At present there are many bodies involved in implementing the Act, but there is no single organisation which is in charge. And the effect of that can be seen in the Act’s patchy implementation. Ministers would still be ultimately responsible for the Act, but placing an independent body in charge would provide a focus for activity to raise awareness and improve practice.

“Our other key finding concerns the Deprivation of Liberty Safeguards. The intention of the safeguards is to provide legal protection for people who are being deprived of their liberty for their own safety. For example, someone with dementia may be prevented from leaving a care home alone because they are at risk of getting lost. The safeguards are there to ensure that such restrictions are not placed on people without good reason, and without considering less restrictive options first. It also provides a means to challenge such arrangements. 

“We were very concerned by what we heard about the safeguards. The evidence suggests that tens of thousands of people are being deprived of their liberty without the protection of the law, and without the protection that Parliament intended. Worse still, in some cases the safeguards are being wilfully used to oppress individuals and to force decisions upon them, regardless of what actions may be in their best interests.

“The criticism of the safeguards extended to the legislative provisions themselves; we were told the provisions were poorly drafted, overly complex and bureaucratic. A senior judge described the experience of trying to write a judgment on the safeguards as feeling “as if you have been in a washing machine and spin dryer”. Even if implementation could be improved, the legislation itself is flawed.

“In the face of such criticism, the only option is to start again. The Government needs to go back to the drawing board to draft replacement provisions that are easy to understand and implement, and in keeping with the style and ethos of the Mental Capacity Act.”

The Committee further recommends that:

•  Government works with regulators and professional bodies to ensure the Act is given a higher profile in training, standard setting and inspections;
• Government increases the staff resources at the Court of Protection to speed up handling of non-controversial cases;
• Government reconsiders the provision of non-means tested legal aid to those who lack capacity, especially in cases of deprivation of liberty;
• Local Authorities use their discretionary powers to appoint Independent Mental Capacity Advocates more widely than is currently the case; 
• Government addresses the poor levels of awareness and understanding of Lasting Powers of Attorney and advance decisions to refuse treatment among professionals in the health and social care sectors;
• Government review the criminal law provision for ill-treatment or neglect of a person lacking capacity to ensure that it is fit for purpose.

The Committee also recommends that the House of Lords seek an update from the Government twelve months from now to find out what they have done in response to their key recommendations.

You can watch a YouTube video of Lord Hardie giving an overview of the Committee’s report by following the link.

Deprivation of Liberty Safeguards (DoLS)

Key findings

• Too many people are waiting too long for a Deprivation of Liberty Safeguards (DoLS) authorisation, despite multiple examples of local authorities trying their best to reduce backlogs and ensure sustainable improvement.
• We remain worried about the rights of people at the heart of the DoLS system. We continue to see people in vulnerable circumstances without legal protection, which not only affects them but also their families, carers, staff and local authorities.
• The system has needed reform for over 10 years. Unless there is substantial intervention, we are concerned that these challenges will continue.

The Deprivation of Liberty Safeguards (DoLS) were introduced under the Mental Capacity Act (MCA) 2005. The safeguards were designed to protect the human rights of people aged 18 or over if they do not have the mental capacity to consent to their care arrangements and they need to be deprived of their liberty. The safeguards apply in care homes and hospitals.

If a person is deprived of their liberty, they are not free to leave the premises on a permanent basis, for example to live where and with whom they choose to, and they are subject to continuous supervision and control. This means they are monitored or supervised for significant periods of the day and they are not allowed to make important decisions about their own life. The safeguards are vital in ensuring that such deprivation of liberty only happens when it is necessary, proportionate and in the person’s best interests.

Concerns have been raised about the effectiveness of the DoLS system for over 10 years. In 2014, the House of Lords MCA post-legislative scrutiny report warned of the lack of understanding and poor implementation of the safeguards, which meant that, “thousands, if not tens of thousands, of individuals are being deprived of their liberty without the protection of the law.”

In successive State of Care reports, we have raised strong concerns about the operation of DoLS, including delays in processing applications and the variable knowledge of staff about the safeguards. Across both health and social care services, we continue to find that many of the issues outlined in the House of Lords report are still relevant 10 years on and have been exacerbated by the stark increase in the volume of applications, bringing new challenges for the DoLS system.

DoLS were due to be replaced by the Liberty Protection Safeguards (LPS). These would have addressed the main limitations of the DoLS system, such as:

• streamlining processes
• extending the scheme to cover 16 and 17-year-olds
• giving families greater involvement
• applying the safeguards to additional settings, including people’s homes and supported living services
• crucially, giving responsibility for issuing authorisations to NHS trusts and integrated care boards, along with local authorities, to reduce the strain on the system.

However, in April 2023, the government announced that the implementation of LPS would be delayed “beyond the life of this parliament”. At present, it is unclear when or if the LPS reforms will be implemented. We are keen to establish a dialogue with the new government about this.

Within a system struggling to cope, in 2023/24 we continued to see people in vulnerable circumstances being left without legal protection with their rights affected. This not only affects people using services but also their families, carers, staff and local authorities.

The chronic backlogs

Ten years ago, a landmark Supreme Court judgement, known as ‘Cheshire West’, clarified and broadened the definition of what constitutes a deprivation of liberty. Since then, applications to deprive a person of their liberty have continued to increase far beyond the levels expected when the safeguards were designed.

This has culminated in local authorities facing unprecedented volumes of DoLS applications, and in many cases, continuing backlogs to process them, as we have reported in previous State of Care reports. In 2023/24, applications to deprive a person of their liberty increased to just over 330,000, an 11% increase compared with the previous year.

The delays in implementing LPS mean that local authorities are still the only organisations able to give a standard DoLS authorisation. To do this, local authorities have 21 days in which to assess whether the deprivation of liberty is appropriate. But in 2023/24, only 19% of standard applications were completed within the statutory timeframe. In recent years, backlogs for processing applications have remained high, with figures showing 123,790 people were waiting for an authorisation as at March 2024.

Applications to deprive a person of their liberty must be authorised by a ‘supervisory body’. In England, the role of a ‘supervisory body’ is undertaken by local authorities, who are responsible for arranging assessments to make sure that a deprivation of liberty is only authorised if certain requirements are met. Standard authorisations can last for up to a year. If a person urgently needs to be deprived of their liberty before they have had a full assessment, providers can grant themselves an urgent DoLS authorisation. These can last up to 7 days and can be extended for a further 7 days if necessary.

We found a wide variation in how local authorities were managing applications in 2023/24. It was clear that some were struggling to process applications promptly enough, and yet one local authority had no backlogs. We continue to hear from our external stakeholders that the DoLS system is “not working” and there is “no movement once the application has been submitted.”

Some local authorities had high numbers of applications waiting to be reviewed, which meant some people had been waiting for an assessment for over a year. We are particularly worried about people’s human rights in these cases, as assessments may highlight that their care is more restrictive than it needs to be. When local authorities can carry out assessments, we have seen how this can identify unnecessary restrictions so that DoLS conditions can be used to mandate that care arrangements are the least restrictive possible.

Variation in backlogs between different local authorities means people in similar situations may have different experiences of the DoLS system because of where they live. Many factors contribute to this variation, including budget allocation, the make-up of local populations, and the number of hospitals and care homes in an area.

Local authority backlogs also have a knock-on impact on hospital and care home staff: while waiting for DoLS applications to be reviewed, they have to balance keeping people safe with protecting their rights. Our inspectors told us about staff feeling stressed and confused trying to navigate the DoLS system when waiting for an authorisation. Worryingly, our inspections and assessments have also highlighted instances where backlogs in processing existing applications mean some care providers have stopped submitting new applications. This means people have restrictions placed on them without an application or any legal safeguards.

Providers must formally notify CQC without delay when they know the outcome of an application for a deprivation of liberty, whether it was made to the Court of Protection or under DoLS. This includes both when an authorisation has not been granted or the application has been withdrawn.

In 2023/24, we received around 161,000 DoLS notifications, a 23% increase from the previous year. Recent changes in data reporting have highlighted some discrepancies between the data collected by local authorities and data we hold on notifications from providers, and we are taking steps to understand the reasons for this.

Behind the backlogs

To better understand the pressure on local authorities, this year we surveyed representatives from the National DoLS Leads Network and heard the views of over 50 respondents from supervisory bodies across England. We heard widespread concern from the local authorities that they are often significantly under-resourced to process increasing volumes of DoLS applications, as their funding has not increased in line with the number of people requiring assessments. One local authority told us:

DoLS is a broken system. It was designed for a pre-Cheshire West time with relatively few applications. It is impossible to make it work with the resources we have, leading to a big backlog…The situation is so bad that, if we just stopped getting any applications and just assessed people from the backlog, we would be doing this for around 18 months just to clear it.

Insufficient staffing levels were also identified as a primary barrier to performance. Many supervisory bodies are struggling to recruit enough assessors, with some local authorities relying significantly on independent assessors to manage the volume of applications. Some respondents noted high staff turnover within DoLS teams, describing working in this area as a “marmite experience” where members of staff either thrive, or more often, leave the service.

Amid these challenging circumstances, a member of our external stakeholder group described local authorities going “above and beyond to create systems that are as safe as possible.” NHS England data shows that the number of applications completed by local authorities has increased over the last 5 years by an average of 9% each year. But while DoLS backlogs decreased by 2% in 2023/24, the number of people waiting for an authorisation remains significant. In our assessments of local authorities, we have seen multiple examples of supervisory bodies trying their best to reduce backlogs and ensure sustainable improvement. For example, many local authorities adopt risk-based approaches and tools to prioritise applications. We also saw local authorities recruiting and training more best interests assessors.

Respondents to our National DoLS Leads Network survey frequently cited the ADASS screening tool as a way of helping local authorities to prioritise applications, by categorising them as either high, medium or low priority. However, this method relies on detailed, accurate DoLS applications. We heard that many local authorities are not always confident that the information services provide on DoLS applications is correct. This increases the risk that people who urgently require an assessment are not being appropriately prioritised. Although tools can help local authorities to identify those in need of urgent attention, the statutory 21-day timeframe applies to all standard DoLS applications and the need to prioritise may be another symptom of a broken DoLS system.

We are also concerned that the use of prioritisation tools may result in some groups of people, such as people with a learning disability or living with dementia, being disproportionately affected by delays in processing DoLS applications. A respondent from the National DoLS Leads Network noted that while these people usually meet the requirements for DoLS, they often do not meet the prioritisation criteria and may be “overlooked”. We also heard from a member of our external stakeholder group about some assessments being carried out virtually. While this may offer greater flexibility, virtual assessments are not always suitable for the people who are being assessed. A member of our external stakeholder group reflected that differences in the way local authorities approach DoLS makes it difficult to support managers of care homes spread across different counties.

Local authorities told us that ongoing issues with the level of understanding of the safeguards among health and social care staff can exacerbate the backlogs. We heard that applications from care homes and acute hospitals are not always appropriate, and we have also seen evidence of this, with some staff unclear on the circumstances that require a DoLS authorisation. This risks people who need the safeguards getting lost in the high volume of referrals, or not having an application made when they need one. Local authorities found that the quality of mental capacity assessments made by providers before they submit an application was sometimes poor, which can also result in unnecessary applications. It also means that they may need to contact providers to get information that should have been included in the application, thereby delaying the process and requiring additional resources from all parties.

Another factor that has a negative impact on the backlogs is a lack of communication between providers and local authorities. When providers apply promptly for DoLS renewals, it can help reduce workloads for supervisory bodies. Yet, we heard this does not always happen in practice. In addition, local authorities are not always informed of important changes following submissions, such as a person dying, being discharged, admitted to hospital or their condition changing. These people therefore remain on the waiting list for DoLS when they may no longer need to be. In other circumstances, providers may also not communicate important changes such as objections or increased restrictions, preventing local authorities from giving priority to some assessments that need it.

Limited understanding of the Mental Capacity Act and DoLS

The Mental Capacity Act 2005 (MCA) directly affects the lives of millions of people. Everyone providing care to people over the age of 16 must be familiar with this vital piece of legislation, which introduced rights and protections for people who may lack mental capacity. A decade after the House of Lords report, we continue to find a lack of understanding of the MCA among providers.

Any action taken as part of the DoLS process must be in line with the principles of the Act. While providers often demonstrate an awareness of the MCA and its principles, many managers and staff still lack confidence in applying them in their work. This is reflected in care records, mental capacity assessments and best interests decisions. We found that some care records did not show how best interests decisions were made and how the appropriate people were involved.

A key principle of the MCA is that people should be cared for in a way that least restricts their rights and freedoms. This principle shines through every aspect of the Act, including DoLS. For example, we saw services routinely reviewing restrictions to check if they remain the least restrictive option, rather than assuming the restrictions continue to be necessary simply because a DoLS authorisation was granted. However, providers continue to have a mixed understanding of DoLS. Some struggle to understand when the safeguards apply and we also saw examples of DoLS applications from providers that:

• did not include capacity assessments
• did not specify what and why specific restrictions were needed
• failed to acknowledge less obvious restrictions that were already being implemented, such as sensor movement trackers or bed rails.

Worryingly, we also heard of a misconception among some providers that a DoLS application equated to an authorisation being in place.

We saw how, in a few services, a lack of person-centred planning and staffing issues meant there were blanket restrictions – depriving all residents of their liberty despite not being necessary for everyone. One local authority also mentioned that some services are still influenced by a “protection imperative” when caring for older people. In their experience, older adults are more likely to have more restrictive care plans in place, as some providers feel a need to reduce risks to the person regardless of their capacity to make specific decisions.

If people lack capacity to make one decision, it is vital that staff do not assume they lack capacity to make all decisions. Yet, we have seen examples of this happening in some services, which could lead to unnecessary restrictions and is not in line with the Act.

Care plans, mental capacity assessments and DoLS authorisations should be reviewed regularly to ensure they remain appropriate. In our last State of Care report, we highlighted that restrictions were not always reviewed often enough, meaning providers may have missed opportunities to reduce them. This may also be a warning sign of a closed culture. When services stop recognising and reviewing restrictions, they risk becoming part of the culture, passed on and accepted by new employees.

Application of the safeguards

In some services for autistic people and people with a learning disability, we have seen DoLS assessments and authorisations that do not consistently show that the least restrictive option has been considered. DoLS authorisations in these services can also lack information on how people’s emotional and physical wellbeing is protected when they are subjected to restrictive practices such as seclusion and restraint. We have previously raised concerns that poor understanding of the MCA and issues with the management of DoLS are contributing to the overuse of restrictive practices and our policy position is clear that the restrictive practices are only appropriate in limited, legally justified, and ethically sound circumstances in line with people’s human rights.

Our assessments highlighted some differences between hospitals and care homes in the way DoLS are applied. Because the length of stay in an acute hospital tends to be shorter than in a care home, DoLS backlogs mean often patients are not assessed before they are discharged or moved elsewhere. This means that people at the heart of the process may not practically benefit from the protection afforded by the safeguards for most of their hospital stay, despite the work and resources used by providers and local authorities to follow the process in line with the law.

Where a person has a DoLS authorisation in place during a hospital stay, we have seen the positive effects of this on their care. For example, in one case the authorisation meant staff were more aware of the patient’s needs, which was evident in care records. By better understanding the patient and tailoring their care, staff were able to prevent escalations.

However, we also identified a lack of communication about DoLS at some acute hospitals, which affected numerous patients on the ward. For example, we found that people sharing a ward with someone subject to a DoLS authorisation did not always know that certain restrictions, like not being able to open locked doors, only applied to one person. In mental health inpatient settings, we continue to see different interpretations of the interface between the Mental Health Act and the Mental Capacity Act, with the safeguards being used more frequently in wards for older adults.

Although staff should be familiar with the conditions for a DoLS authorisation, this is not always the case. We identified limited oversight of DoLS at some services and we are concerned that the safeguards are viewed as a ‘management issue’ rather than something every team member needs to engage with to protect people’s human rights. A local authority also told us that frequent staff and management changes in care homes represents a challenge, as local authorities do not have the resources to regularly undertake in-depth work with providers to improve their understanding and application of DoLS.

While there is a clear need for further training, we found examples of a lack of training on DoLS in anticipation of the introduction of the Liberty Protection Safeguards. A member of our external stakeholder group explained that providers had invested energy preparing for LPS and some were finding it difficult to adjust to uncertainty around its implementation at such a late stage. However, it is vitally important that services ensure staff have adequate knowledge of DoLS to protect people’s human rights – both now and in the future.

New registrations and the Mental Capacity Act

Concerns around providers’ knowledge of DoLS and the MCA are mirrored in an analysis of our regulatory enforcement data on Notices of Proposal. At the point of registration, we expect all providers to demonstrate a clear understanding of the MCA and, when applicable, DoLS. As the regulator, we will serve a Notice of Proposal to impose conditions on a new provider or refuse registration if they cannot demonstrate this. We analysed a sample of 139 Notices of Proposal issued in 2023/24 to new adult social care providers and managers applying to register with CQC. This found that almost half the Notices (66) were based on a lack of compliance with standards outlined in the Mental Capacity Act (MCA). In many cases, applicants also failed to demonstrate compliance with other regulations.

Of the Notices of Proposal relating to the MCA, nearly all were refused applications because the applicant lacked vital knowledge in this area. For example, one applicant could not demonstrate that they understood how and when to use restraint. We were concerned that another applicant had a poor understanding of mental capacity, which presented a risk that consent may be gained from a person who is not legally able to give it.

Some Notices of Proposal were issued because applicants could not provide evidence that they would implement the principles of the MCA effectively. One applicant was aware that a representative with appropriate power of attorney was able to provide legal consent, but for people without a power of attorney, there was nothing else in place to ensure that people would benefit from the rights and safeguards afforded by the MCA. It is key that services and managers applying to register with CQC, and their staff, are aware of their responsibilities under the Act, to respect people’s rights in line with both the MCA and Health and Social Care Act regulations.

People’s experience and involvement

DoLS are essential human rights safeguards that were designed to protect people in vulnerable circumstances. Multiple members of our external stakeholder group told us about waiting years for responses to some DoLS applications. This leaves people without legal protection, and some do not have accessible routes to challenge their deprivation of liberty. In some cases, people are receiving overly restrictive care that is not aligned with their needs and does not respect their autonomy. Our updated human rights approach makes clear that care that does not respect and promote human rights is neither safe nor high quality.

Our last State of Care report highlighted how a lack of communication around DoLS authorisations can affect people and their friends and families. It is important that people subject to a DoLS authorisation, their families, and carers have the information they need to understand the process and allow them to advocate effectively. One member of our external stakeholder group felt care settings are getting better at explaining the safeguards and people’s rights, which they linked to the presence of best interests assessors being a “valuable education component”.

However, we remain concerned about issues with communication. Many respondents to the National DoLS Leads Network survey noted confusion and upset among family members who are often unaware that a DoLS application has been made until being contacted by an assessor. Our external stakeholder group echoed this, with many sharing experiences of people and families who felt excluded or unheard. One care home provider explained that relatives of residents who had been determined to lack capacity by a hospital have often not been informed about DoLS, and are surprised when care home staff explain the Mental Capacity Act and DoLS process to them. Another member of the group highlighted that the DoLS process can be very confusing for patients and families, stressing the need for time, patience and a point of call for any questions.

We are particularly concerned about communication around DoLS for people who do not speak English as a first language or who use alternative ways of communicating. For example, we found that some acute hospitals were limited in being able to communicate with patients with a DoLS authorisation in any way other than verbally. Whereas using an alternative form of communication such as Makaton may have helped some patients to understand what was happening to them. Our external stakeholder group spoke of concerns around language barriers and inadequate interpretation services, which caused distress to people using services and their family members. One stakeholder felt these issues can be compounded by poor cultural competency among staff, which can lead to poorer care, less effective interventions, and reduced engagement with services.

Several local authorities felt that more challenges to DoLS authorisations have been brought to the Court of Protection in recent years. When a DoLS authorisation is in place, people have a right to have these arrangements reviewed by a court. It is positive that people are aware of their rights to challenge a deprivation of liberty and are supported to do so. However, a local authority also told us that this can be a time-consuming process, which has a further impact on their resources.

Earlier in this report, we raised concerns about older teenagers who may fall through the gaps when accessing mental health services. Similar concerns about the quality of transitions from children to adult services have emerged through our DoLS survey, with one local authority noting that a ‘start again syndrome’ may happen when a young person enters adult services. They said the information provided by children’s services is often insufficient for planning a DoLS application, which can lead to delays in the DoLS process when the person turns 18. At present, the Court of Protection is also responsible for authorising a deprivation of liberty for young people aged 16 and 17 who lack mental capacity, as DoLS only applies to adults. We heard some frustration from local authorities about delays in LPS implementation, as the new scheme would have helped to speed up authorisations for these young people. Like the DoLS process for adults, we have heard that there continue to be delays associated with the Court of Protection authorisation process.

Protecting people in the future

The DoLS system has needed reform for over 10 years. Unless there is substantial intervention, we are concerned that these challenges will continue, leaving people at the heart of this process without the key human rights safeguards that the DoLS system was intended to offer.

In 2023/24, approximately half of the total number of DoLS applications completed were closed without any assessments happening. This means that, in many cases, the DoLS application process may not bring increased safeguards for people’s human rights, despite the efforts and resources used by care homes and hospitals to submit applications, and local authorities’ work to process and triage these.

With the volume of applications continuing to increase, the current system means that local authorities remain the only organisations able to process them, and many have told us they do not have sufficient resources to cope with the demand. Supervisory bodies told us that increased funding, an updated Code of Practice, better training and regulatory oversight are all factors which could help to improve outcomes for people while we wait for the LPS to be implemented.

While we heard that DoLS remains an “overly bureaucratic system”, local authorities across England have also implemented some improvements to help existing processes run more smoothly. These include:

• making assessments proportionate and using equivalent assessments when appropriate
• streamlining administrative processes, using IT systems and updating forms
• developing strong working relationships between local authorities and providers to improve communication, especially when circumstances change or when a renewal is due
• workshops and training for providers to reduce the number of inappropriate applications they receive and improve the accuracy of applications.

Despite these efforts, we remain concerned that the number of people requiring the legal protection afforded by DoLS continues to increase and the system is unable to cope with this demand. Ongoing issues with the DoLS system will disproportionally affect certain groups, such as disabled people and older people, who are more likely to need the safeguards. A recent report by Age UK highlighted that in 2022/23, 84% of DoLS applications were made for people aged 65 or over, and almost 50,000 people died while waiting for their application to be processed. Reflecting on the operation of DoLS, the charity said, “The reality therefore is that the rights of some of the most vulnerable older people in our society have been and continue to be routinely denied.”

Too many people are waiting too long for a DoLS authorisation, while variation in the level of knowledge of staff means that others may not have a DoLS authorisation in place when they need one. For many, the current DoLS system is not providing the vital safeguards they need. After a decade of chronic and widely documented issues, urgent action is required to ensure the system does not continue to fail people in the future.

The “Cheshire West case” refers to a landmark 2014 UK Supreme Court ruling, P (by his litigation friend the Official Solicitor) v Cheshire West and Chester Council, which established the “acid test” for deprivation of liberty. It ruled that a person is deprived of their liberty if they are under continuous supervision and control and are not free to leave, regardless of their reasons for being there or their level of objection. This ruling expanded the definition of deprivation of liberty and clarified that anyone in this situation, who lacks the mental capacity to consent, must have their confinement authorised by the Court of Protection or the Deprivation of Liberty Safeguards (DoLS) process.  

Key aspects of the ruling:

• The “acid test”: To determine if a person is deprived of their liberty, the key questions are:
  • Is the person under continuous supervision and control? 
  • Is the person not free to leave? 
• Objective and subjective elements: The ruling confirmed that a deprivation of liberty is determined by an objective test of the care arrangements, which then requires a subjective test of whether the person lacks the mental capacity to consent to their confinement. 
• Impact on care: The ruling made it more difficult to place vulnerable individuals in care homes or other settings without the proper legal authorisation, and it expanded the use of the DoLS process to ensure legal protection for those deprived of their liberty. 
• Legal consequences: The judgment requires that any deprivation of liberty for a person lacking capacity must be authorised either by the Court of Protection or by following the Deprivation of Liberty Safeguards (DoLS) process. 

DHSC urges Supreme Court to overturn ‘clearly wrong’ Cheshire West ruling on deprivation of liberty

Government says ‘acid test’ set out in landmark 2014 ruling deviated from European Court of Human Rights case law, however charities have warned that its intervention risks removing vital safeguards from disabled people

By Mithran Samuel on October 16, 2025 in Adults, Social work leaders

The UK government has urged the Supreme Court to overturn its landmark Cheshire West judgment on deprivation of liberty in a case that will be heard next week.

In an intervention in the case, which will be heard from 20-22 October, the Department of Health and Social Care (DHSC) said the 2014 judgment was “clearly wrong” because it departed from European Court of Human Rights (ECtHR) case law in relation to the definition of a deprivation of liberty.

However, its intervention has been strongly criticised by charities Mencap, Mind and the National Autistic Society as “deeply troubling” and risking the removal of vital safeguards from thousands of disabled people.

Cheshire West’s impact

Cheshire West significantly widened the definition of a deprivation of liberty compared with what had previously been the case in England and Wales, leading to a huge spike in the number of cases requiring authorisation through the Deprivation of Liberty Safeguards (DoLS) or a Court of Protection order.

The number of Deprivation of Liberty Safeguards (DoLS) referrals hit a new high in 2023-24 but practitioners managed to cut backlogs, official figures have shown.

Care homes and hospitals made 332,455 applications to deprive a person of liberty for their own protection last year, up 11% on the figure for 2022-23, according to NHS England’s annual DoLS data.

Reduction in DoLS backlogs and timeframes

However, despite this, council DoLS practitioners managed to curb both case backlogs and timeframes on the back of a 12% rise in the number of applications they processed during 2023-24, to a record 323,870.

While the average duration of cases remained well above the 21-day statutory timeframe for standard DoLS applications, it fell from 156 to 144 days from 2022-23 to 2023-24.

And the number of uncompleted applications at 31 March 2024 fell by 2% year on year, from 126,100 to 123,790.

About the Deprivation of Liberty Safeguards

• DoLS provides a statutory procedure in England and Wales for authorising the deprivation of liberty of people for care or treatment, as required under Article 5 of the European Convention of Human Rights.
• Care homes or hospitals (‘managing authorities)’ must apply to councils or Welsh health boards (‘supervisory bodies’) to authorise a prospective or existing deprivation.
• Supervisory bodies must then assess whether the six qualifying requirements are met: that the person is 18 or over, has a mental health condition and lacks capacity to consent to the deprivation; that the deprivation does not conflict with requirements of the Mental Health Act 1983, a prior advanced decision by the person or the decision of a Court of Protection-appointed deputy or a donee of lasting power of attorney; and that being deprived of their liberty is in their best interests, necessary to protect the person from harm and a proportionate response to the severity or likelihood of that harm.
• The last of those checks is carried out by a best interests assessor, who is typically a social worker and generally co-ordinates the assessment process.
• Where the qualifying requirements are met, the supervisory body grants the managing authority a ‘standard authorisation’ to deprive the person of their liberty for a maximum of 12 months.
• The DoLS process must be completed within 21 days, other than when the managing authority has granted itself an ‘urgent authorisation’ to deprive the person of their liberty, in which case it should take seven days.

The figures showed that DoLS practitioners processed more than three times as many cases in 2023-24 compared with 2015-16 (105,055), during which time the number of referrals less than doubled.

As has been the case since 2019-20, more completed applications were not granted in 2023-24 (181,940) than granted (141,925).

Uncompleted assessments

However, for the first time, the data demonstrated that, in the vast majority of cases where an authorisation was not granted, the application was closed without an assessment being started (162,655) or completed (15,270). Where an assessment was completed – in 145,945 cases – 97% resulted in a DoLS authorisation.

In cases that were closed without an assessment being carried out, this was likely to be because the person’s circumstances had changed or they had died before the process could be started.

Unsurprisingly, these cases were concentrated in acute hospitals, where DoLS authorisations are required relatively briefly during a treatment episode.

Of 100,550 applications made by acute hospitals in 2022-23, just 4,645 resulted in a completed assessment.

Under the Court of Appeal’s judgment in R (Ferreira) v HM Senior Coroner for Inner South London [2017], there is no requirement for a DoLS authorisation in cases where a person is receiving life-saving treatment that did not differ from what would be given to a person without a mental health problem.

deprivation of liberty, Deprivation of Liberty Safeguards

Policy Critique: Form OPG130 and the Risk of Procedural Injustice in the Safeguarding Process

Executive Summary

Form OPG130, issued by the Office of the Public Guardian (OPG), is intended as a tool to report concerns about the conduct of an attorney or deputy acting under a Lasting Power of Attorney (LPA) or Enduring Power of Attorney (EPA). While the objective of safeguarding vulnerable donors is legitimate and necessary, the design and operational use of this form raise significant concerns about procedural fairness, the presumption of innocence, and the potential for reputational and legal harm to individuals accused of abuse without evidence.

This critique highlights key flaws in the current policy underpinning Form OPG130, particularly the use of pre-determined abuse categories and the ease with which an individual may be named as a perpetrator without recourse to immediate defence or redress. The form’s structure and implementation risk facilitating unsubstantiated allegations, undermining natural justice, and ultimately diminishing trust in the safeguarding framework.

Overview of Form OPG130

Form OPG130 allows any person to report concerns about a donor’s welfare or decision-making arrangements. The form includes:

• A list of pre-defined abuse categories (e.g., financial, physical, emotional)
• Fields for describing incidents or concerns
• A section to name the person(s) alleged to be responsible

The OPG uses this information to determine whether further investigation or referral is warranted. However, the form’s design and handling processes merit critical examination.

Pre-Determined Abuse Categories: Oversimplification and Presumption

The form presents a tick-box list of abuse types without requiring the complainant to demonstrate a credible threshold of evidence. These categories—while reflective of genuine safeguarding concerns—are problematic in policy terms due to:

• Subjectivity: Terms like “emotional abuse” or “neglect” lack clear, uniform definitions in lay usage and may be applied inconsistently.
• Ease of allegation: The form allows serious allegations to be made without scrutiny, inadvertently lowering the bar for potentially harmful or false claims.
• Implied validation: By embedding abuse categories in the form’s structure, the OPG may be seen to lend credence to claims at the point of receipt, regardless of merit.

From a policy design standpoint, this introduces a presumption that once an allegation is made, it holds sufficient weight to prompt intervention—even absent corroborating evidence.

Identification of ‘Perpetrator’: Accusation Without Defence

The form explicitly invites the complainant to name an individual they believe to be responsible for the alleged abuse. Critically:

• No evidentiary threshold is required at the time of submission.
• The accused is not notified at this early stage and therefore lacks the opportunity to respond in real time.
• The allegation is effectively recorded in an official safeguarding process, potentially triggering investigations and reputational consequences.

This policy design runs counter to fundamental principles of fairness and accountability. It lacks procedural balance and undermines the presumption of innocence, creating a high risk of injustice to those accused.

Absence of Safeguards Against Malicious or Misguided Reporting

There is currently no clear mechanism within Form OPG130 to:

• Vet the credibility or motivation of the complainant at the initial reporting stage;
• Require declarations of truthfulness under penalty of law;
• Penalise false or malicious reports.

This gap in policy fails to protect individuals from being targeted as part of family disputes, inheritance conflicts, or personal grievances unrelated to actual abuse. The absence of meaningful safeguards creates a significant risk of misuse.

Disproportionate Consequences and Asymmetric Rights

The policy framework surrounding Form OPG130 allows potentially severe consequences to flow from unsubstantiated allegations:

• Suspension of powers of attorney
• Disruption of care arrangements
• Reputational and emotional harm
• Referrals to safeguarding boards or police

In contrast, the accused has no structured pathway to rebut or contextualise the allegation at the outset. The process is asymmetrical, offering protections to the complainant but none to the accused. This undermines legal norms such as:

• Audi alteram partem – the right to be heard
• Equality of arms in quasi-judicial processes
• Proportionality of state intervention

From a public policy perspective, this imbalance erodes trust in safeguarding systems and may deter capable attorneys from continuing in their roles.

Policy Recommendations

To ensure that safeguarding mechanisms remain fair, effective, and accountable, the following reforms to Form OPG130 and its associated procedures are recommended:

Evidentiary Threshold

Require complainants to provide specific supporting information and, where possible, documentary evidence to substantiate allegations.

Declaratory Statement

Include a formal declaration that allegations are true to the best of the complainant’s knowledge, with a warning about the legal consequences of false reporting.

Initial Credibility Screening

Introduce a triage mechanism within the OPG to assess the plausibility and seriousness of allegations before any formal investigative steps are taken.

Right of Reply

Establish a structured process for notifying accused individuals and offering a prompt opportunity to respond before further action is initiated, except in urgent risk cases.

Transparency and Record-Keeping

Ensure that accused individuals are informed of any allegations retained in official records and have access to a clear process for rectification or removal of unfounded accusations.

Guidance and Training

Provide clear public guidance on what constitutes different types of abuse and the threshold for reporting, to reduce misunderstanding and inappropriate referrals.

Form OPG130, as currently implemented, lacks adequate safeguards to prevent misuse and fails to uphold key principles of natural justice. While protecting vulnerable individuals is a core function of the Office of the Public Guardian, this must not come at the expense of procedural fairness or the rights of those accused.

A rebalancing of the policy framework is urgently required to preserve the integrity of the safeguarding process, protect all parties involved, and ensure public confidence in the operation of powers of attorney.

Critical Analysis of Form OPG130: Concerns About a Donor (LPA/EPA) – Focus on Pre-Determined Abuse Categories and Injustice Toward the Accused

Introduction

Form OPG130, issued by the Office of the Public Guardian (OPG) in the United Kingdom, is designed to allow concerned individuals to report suspicions of abuse regarding a donor under a Lasting Power of Attorney (LPA) or an Enduring Power of Attorney (EPA). While the safeguarding of vulnerable individuals is a crucial function of the OPG, the design and structure of OPG130—particularly the use of pre-determined abuse categories and the approach to identifying alleged perpetrators—raises significant concerns about procedural fairness, natural justice, and the rights of the accused.

Pre-Determined Categories: Presumption of Guilt

The form lists predefined categories of abuse such as:

• Financial abuse
• Physical abuse
• Emotional or psychological abuse
• Neglect
• Sexual abuse

These categories, while reflecting real and serious types of harm, may lead to unintended consequences when placed on a reporting form without context or an evidentiary requirement. The issue lies not in their inclusion per se, but in how they are presented:

• Tick-box simplicity: The form allows allegations to be made simply by ticking boxes. There is often no requirement for substantial evidence, corroboration, or detailed narrative beyond what the reporter chooses to provide.
• Ambiguity and subjectivity: Terms like “emotional abuse” or “neglect” can be highly subjective and open to interpretation. In family or care contexts, particularly those involving complex dynamics or disagreements over care decisions, such labels can be misused or misunderstood.

By structuring the form this way, the OPG risks encouraging speculative or malicious allegations under the guise of safeguarding, with little scrutiny at the reporting stage.

Identification of the ‘Perpetrator’ Without Evidence

Perhaps the most troubling aspect of the form is the section that invites the reporter to name the “person responsible for the abuse”—effectively labelling an individual as a perpetrator before any investigation has taken place.

• No burden of proof: The form does not ask the reporter to present evidence beyond their own account. There is no legal threshold to meet before someone’s name is recorded as a suspected abuser.
• Impact on the accused: Once named, a person can be subjected to investigations, reputational damage, and distress—all before they are even notified of the allegation, let alone given a chance to respond.
• No right to immediate response: The accused does not have automatic recourse to challenge the allegation at the point of submission. The OPG may begin inquiries or refer matters to social services or police without the accused having the opportunity to correct inaccuracies or defend themselves.

This dynamic can result in serious miscarriages of justice, particularly where allegations are made maliciously, based on misunderstandings, or as a result of personal disputes.

Injustice and the Erosion of Natural Justice

At the heart of the criticism is a fundamental lack of procedural fairness—commonly referred to as natural justice. The principles of natural justice include:

• The right to a fair hearing
• The right to be informed of allegations
• The right to respond to and challenge those allegations
• The right to an impartial investigation

Form OPG130, in its current structure, undermines these principles:

• No balancing mechanism: There is no equivalent form or process for an accused person to formally respond at the same stage. The investigative process may not include or prioritize the perspective of the accused until later—if at all.
• Risk of disproportionate responses: The mere presence of an allegation may trigger significant interventions, such as suspension of powers or referral to authorities, regardless of whether the claims are substantiated.
• No penalties for false allegations: There appears to be no clear warning on the form about the consequences of making false or malicious accusations, which would serve as a deterrent to misuse.

Potential for Abuse of the Safeguarding Process

Ironically, a form intended to prevent abuse may itself be vulnerable to being used abusively. Disputes over finances, inheritance, family dynamics, or care decisions may prompt individuals to use the form as a weapon—especially when there is no immediate scrutiny of their motives or evidence.

This creates a paradoxical situation:

• The vulnerable party may become more vulnerable: Disruption caused by false allegations can destabilize care arrangements or damage trust between the donor and attorney.
• The accused may suffer irreversible harm: Reputational damage and emotional distress can occur even if the allegations are ultimately dismissed.

While the safeguarding of donors under LPAs and EPAs is undeniably important, Form OPG130 in its current form presents serious concerns about fairness and justice. The use of pre-determined categories of abuse and the ease with which an individual can be labelled a perpetrator without evidence or recourse undermines the principles of due process and opens the door to misuse.

To align better with principles of justice and the rights of all parties involved, the OPG should consider reforms such as:

• Introducing a requirement for supporting evidence
• Ensuring allegations are screened for credibility before action
• Providing an immediate and equal opportunity for the accused to respond
• Including clear warnings about the consequences of false reporting

Safeguarding systems must protect the vulnerable, but they must also guard against the abuse of the process itself. Without a balance, the very tools designed to uphold justice may become instruments of injustice.