Summary: Ms X complained the Council failed to follow statutory guidance and its own policies when it held an Initial Child Protection Conference regarding her child, Y. The Council was at fault for failing to provide Ms X with all the reports for the conference. There was also fault in the Council’s record keeping. The Council has already apologised for the faults, and this was sufficient to remedy any injustice caused.

The complaint

1. Ms X complained the Council failed to follow statutory guidance and its own policies when it held an Initial Child Protection Conference regarding her child, Y.
2. Ms X says the Council’s decision to place Y on a child protection plan was flawed and the matter has caused her distress and frustration.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We provide a free service but must use public money carefully. We do not start or continue an investigation if we decide:
• any fault has not caused injustice to the person who complained, or
• any injustice is not significant enough to justify our involvement, or
• further investigation would not lead to a different outcome.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

5. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
6. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
7. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).

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How I considered this complaint

8. I considered the information Ms X provided.
9. I considered information the Council provided.
10. Ms X and the Council had the opportunity to comment on the draft decision. I considered comments before I made a final decision.

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What I have and have not investigated

11. Ms X complained she did not receive reports from Y’s GP or school before the Initial Child Protection Conference (ICPC).
12. We investigate complaints about councils and certain other bodies. We cannot investigate the actions of bodies such as GPs or the NHS. (Local Government Act 1974, sections 25 and 34(1), as amended)
13. We cannot investigate most complaints about what happens in schools. This includes the school’s report for the ICPC. (Local Government Act 1974, Schedule 5, paragraph 5(2), as amended)

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What I found

Relevant Law and Guidance

Duty to make child protection safeguarding enquiries

14. Under section 47 of the Children Act 1989, where a council has reasonable cause to suspect that a child in their area is suffering or is likely to suffer significant harm, it has a duty to make such enquiries as it considers necessary to decide whether to take any action to safeguard or promote the child’s welfare. Such enquiries should be initiated where there are concerns about abuse or neglect.
15. Section 47 of the Act places a duty on agencies, but mainly the council and the police, to make “such enquiries as they consider necessary to enable them to decide whether to take action to safeguard or promote the welfare of a child in their area”.
16. If the information gathered under section 47 supports concerns and the child may remain at risk of significant harm the social worker will arrange an initial child protection conference (ICPC). The ICPC decides what action is needed to safeguard the child.

Child Protection Conference arrangements

17. The Child Protection Conference decides what action is needed to safeguard the child. This may include a recommendation that the child should be supported by a Child Protection Plan.
18. The Child Protection Conference is a multi-agency body and is not in itself a body in the Ombudsman's jurisdiction.
19. The Child Protection Conference plays an advisory role. But the final decision, for example whether to place a child on a Child Protection Plan or to discontinue a Plan, is the responsibility of the council. We would generally consider it appropriate for a council to follow the recommendations of the Child Protection Conference unless there was good reason not to.

Pan-London child protection conference procedures

20. The Council follows the pan-London child protection safeguarding procedures.
21. The procedures say Initial Child Protection Conferences should be attended by the local authority’s children’s social care team, and at least two other professional groups or agencies that have had direct contact with each child who is subject to the conference to be quorate.
22. The procedures say this minimum may be breached where a child has not had relevant contact with three agencies, or where sufficient information is available, and where a delay would be detrimental to the child. In this scenario, the chair should record the meeting is not quorate and the reasons for proceeding.
23. The procedures also say the Council’s children’s social care team should provide the ICPC with a written, signed report. The social worker’s report for the ICPC should be shared with families where appropriate at least two days before the conference.
24. All other agencies working with the family should write a report for the conference and share it with the family where appropriate. The reports for an ICPC should be available at least two days before the conference date.

The Council’s policy on conference calls for child protection conference meetings

25. The Council has a policy, the “Hybrid Child Protection Conferences in Tower Hamlets”. The policy says since the COVID-19 pandemic, the Safeguarding and Quality Assurance Service transitioned to utilising virtual child protection conferences.
26. The policy says parents/ carers can have a hybrid (mixture of physical and virtual attendance) if it better suits their needs.
27. The policy says priority will be given to certain professionals, including interpreters and advocates, with a maximum of either four or five people able to attend in-person. All other attendees will be sent an invitation to join a conference video call.

Council’s policy on appealing Child Protection Conference decisions

28. The Council has a policy, the “Child Protection Appeals Protocol”.
29. The policy says appeals will be considered in two stages:
• At stage one, the Council will review the information available and send a response within five working days of receipt of the complaint.
• At stage two, the appeal will be considered at a multi-agency meeting. After the meeting, the complainant will receive the Council’s decision within 15 working days of the original stage two request.

School nurses

30. The Council is responsible for commissioning school nurses though its public health duties. School nurses are public health nurses who lead and deliver the Healthy Child Programme for school-aged children and young people.

What happened

31. Below is a summary of key events. It is not a comprehensive overview of everything that happened.
32. Ms X has a child, Y, who is of primary school age. In June 2022 following private court action by Y’s parents, a Child Arrangements Order (CAO) was made by the courts which said Y would spend part of the week with Ms X, and part of the week with their father. During late 2022, Ms X stopped sending Y to school two days per week because she had concerns about their safety. In January 2023 Ms X took court action to have the CAO amended.

Strategy discussion and s47 investigation

33. In late February 2023, the Council held a strategy discussion meeting due to concerns about Y’s care. The social work team manager, social worker, Y’s GP, behaviour and attendance officer, their team manger, the school nurse, Y’s school, and the police attended the meeting.
34. The record shows professionals had concerns including, but not limited to, Y’s school attendance, Y being exposed to parental conflict, and Y’s emotional presentation at school.
35. All professionals agreed an Initial Child Protection Conference (ICPC) should be held to discuss the concerns about Y.
36. A section 47 enquiry was completed, which recommended a social worker complete a child and family assessment and recommended to proceed with an ICPC.

Social work report

37. A social worker completed a child and family assessment regarding Y and their family. They also recommended an ICPC should take place.
38. The social worker shared their report with Ms X several days before the ICPC. Ms X said the report she was given was a draft copy, unsigned by the social work team manager.
39. The social worker’s report was signed by the team manager two days before the ICPC. They summarised the concerns contained in the social worker’s report. This version was shared with Ms X on the day of the ICPC.

Initial child protection conference

40. In mid-March 2023 the Council held an ICPC. The record shows Ms X, the chairperson, and Y’s social worker attended in person.
41. The clerk, police, Y’s school, and the school nurse attended virtually via video conference call. The school nurse did not send a report. The behaviour and attendance officer did not attend but sent a report. The GP did not attend and did not provide a report.
42. The conference chair recorded the meeting was quorate and noted they met Ms X before the meeting.
43. The chairperson recorded a summary of the discussion held. They recorded concerns about Y’s needs not being met. The record shows all professionals at the meeting agreed Y should be placed on a child protection plan. The chairperson recorded the decision that Y was at risk of significant harm and Y was made subject of a child protection plan under the category of neglect.

Stage one appeal

44. In early March 2023, Ms X appealed the Council’s decision to place Y on a child protection plan. Eight days later, she sent additional information and documents to the Council. The Council summarised Ms X’s concerns as:
• the ICPC was not run properly in accordance with the pan-London procedures;
• the wrong decision was made in making the child protection plan; and
• the plan was not made in the best interest of Y.

Stage one appeal response

45. The Council sent a stage one appeal response ten working days after Ms X’s stage one appeal request. The reviewing officer apologised for not being able to call Ms X before sending the decision. They offered to speak with Ms X later.
46. The Council did not uphold six of Ms X’s summarised complaints but upheld one. It said:

47. Ms X disagreed with the Council’s response and submitted a stage two appeal in mid-April 2023.

Stage two appeal response

48. The Council held a review panel 27 working days later in mid-May 2023. The panel included senior representatives from children’s services, health, the police, and education safeguarding.
49. The Council sent Ms X its stage two outcome letter 37 working days after her stage two appeal request.
50. The Council apologised for the delay in sending the stage two response. It told Ms X the stage two panel upheld all the stage one findings. It found the stage one response was thorough and provided detailed feedback to support the findings.
51. The Council reiterated that its guidance for hybrid meetings was adapted to allow virtual attendance at meetings. It said it would consider conducting in-person meetings in the future if that is the wish of the family.
52. The Council acknowledged there were technical issues with some of the video conferencing equipment, but noted once the issues were resolved the meeting could continue without issue. It apologised for the delay this caused.
53. The Council accepted not all the reports from professionals were shared with Ms X in advance of the ICPC. It explained it was pursuing the matter through its partnership meetings to ensure professionals are reminded of the need to share their reports in advance of child protection conferences.

Ms X’s complaint to the LGSCO

54. Ms X remained unhappy with the Council’s response and brought her complaint to us.
55. In response to my enquiries, the Council said:
• it acknowledged the timescales for completing the review of Ms X’s appeal were not adhered to and it was sorry for this;
• it would make enquiries to establish if Ms X had received a copy of the behaviour and attendance officer’s report;
• Ms X was given a copy of the social worker’s final report at the ICPC;
• the school nurse did not write a report because they were not working with the family at the time;
• explained it had reflected on its processes and said it would record in children’s records when professional’s reports have been shared with parents; and
• it acknowledged all partner agencies should share reports before a child protection conference. It sent us evidence of raising the matter in a sub-committee meeting.

Analysis

56. We are not an appeal body. Our role is to review the process by which decisions are made. We look for evidence of fault causing a significant injustice to the individual complainant.

Quorum

57. The pan-London child protection procedures say for a child protection conference to be quorate, children’s social care and two other agencies that have had direct contact with the child should attend the meeting. The evidence shows children’s social care and Y’s school attended the conference. Both agencies had direct contact with Y.
58. However, the school nurse and police did not have direct contact with Y. Y’s GP had direct contact with Y but did not attend. The Council’s behaviour and attendance officer did not attend the meeting. The Council recorded the meeting was quorate, but because only two agencies that had direct contact with Y attended it was not. This was poor record keeping and was fault.
59. While this is the case, the pan-London guidance also allows the chair of the conference to proceed in certain circumstances, including when sufficient information is available and when a delay would be detrimental to the child.
60. Based on a balance of probabilities, I consider it more likely than not the Council would have proceeded with the conference. This is because the Council had all the information necessary from the professional reports and the representatives that attended the meeting to allow it to make its decision. Therefore, further investigation is unlikely to achieve a different outcome.

Professional reports for the ICPC

61. Ms X complained she was not provided with professional reports in advance of the conference. From the Council, this included the social worker’s final report signed by the team manager, and the behaviour and attendance officer’s report. Ms X also said there was no report from the school nurse.
62. The evidence shows the Council gave Ms X the social worker’s report several days before the conference. The report was signed by the social worker, but not the team manager. The pan-London guidance says the report should be the final, signed version. This was fault.
63. However, because the report provided to Ms X prior to the ICPC contained most of the same information as the version signed by the team manager aside from the team manager’s comments, this did not cause Ms X a significant injustice. Ms X was aware of the Council’s concerns and was able to consider them before the ICPC. As a result, we will not consider this matter further.
64. The behaviour and attendance officer did not share their report with Ms X. This was fault. The Council accepted fault and apologised to Ms X. During our enquiries, the Council said it would check Ms X has now received the report. These actions are sufficient to remedy any injustice caused. Ms X was aware of the Council’s concerns about Y’s school attendance, and therefore she was not disadvantaged during the ICPC process because she had not received the behaviour and attendance officer’s report.
65. The Council explained the school nurse had no active involvement with Y at the time of the conference, therefore they did not submit a report. This is not fault.
66. The Council explained it had learned from the concerns Ms X raised and said it would ensure children’s records include details of when professional reports are shared. This is an appropriate action.

Virtual conference meetings

67. The Council’s policy says child protection conferences are, by default, attended via conference call since the COVID-19 pandemic. Parents and carers are offered the opportunity to attend in-person, which Ms X did.
68. While there were some initial technical difficulties with the conference equipment, the ICPC was able to proceed, and the record shows the attendees were able to engage in the conference and express their views. This was not fault.

Council’s appeal process for the initial child protection conference

69. The Council’s stage one and stage two responses to Ms X’s appeals were delayed. The Council accepted the delay was fault and apologised to Ms X. This was sufficient to remedy any injustice caused.

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Agreed action

70. Within four weeks of the final decision, the Council agreed to:
• provide us with evidence it has sent Ms X the attendance and behaviour officer’s report for the Initial Child Protection Conference;
• remind child protection conference chairs of the pan-London guidance regarding quorate Child Protection Conferences; and
• remind child protection conference chairs that, where a Child Protection Conference is not quorate, but the chair decides to proceed in any event, they should record their reasons.
71. The Council agreed to provide us with evidence it has complied with the above actions.

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Final decision

72. I ended the investigation. I found fault, and the Council has already remedied the injustice caused. I also made service improvement recommendations to prevent recurrence of the fault.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman