Summary: Mr and Mrs Y complain about the Council’s handling of an Initial Child Protection Conference. The Council has accepted it was at fault and taken certain action to remedy some of the injustice Mr and Mrs Y experienced. The Ombudsman finds the Council at fault for failing to fully assess the distress, uncertainty and confusion caused to Mr and Mrs Y. To remedy this injustice, the Council has agreed to apologise to Mr and Mrs Y, make a payment to them and make several service improvements.

The complaint

1. The complainants, who I shall refer to here as Mr and Mrs Y, complain about the Council’s handling of an Initial Child Protection Conference. They complain the Chair of the Child Protection Conference:
1. was not independent and seemed to have a view from the beginning about the outcome she wished to achieve. For example, the Chair asked social work representatives twice whether the threshold for a Child Protection Plan had been reached;
2. responded to Mrs Y’s despair with aggressive behaviour;
3. failed to respond when Mr and Mrs Y raised concerns about the Chair bringing up other alleged injuries to their daughter, B, that were unsubstantiated, but instead became more aggressive and defensive;
4. incorrectly told Mr and Mrs Y there were only two possible outcomes of the Conference when there were three. They complain other professionals present failed to correct the Chair;
5. shared photographs of the alleged injury to B outside of the Conference when one parent was not present and despite saying the investigating social worker should not have taken the photograph;
6. at the end of the Conference, asked for B’s case to be discussed separately to Mr and Mrs Y's other two children, which they say was to make sure B was put on a Child Protection Plan;
7. failed to make sure there was sufficient input from professionals who knew the family well; and
8. created an environment of fear through the way she carried out the Conference.

Mr and Mrs Y also complain that the Council:

9. made enquiries that informed its stage one complaint response without involving Mr Y;
10. treated them differently to other parents because of their professions and being local adoptive parents; and
11. failed to explain why the Council considered a second investigation was necessary (under section 47 of the Children Act 1989).
9. Mr and Mrs Y say the situation has significantly negatively impacted their mental health and ability to work. They say the situation has affected their family relations. The complainants say they and their three daughters have experienced serious distress.
10. Mr and Mrs Y say they have paid £1200 in legal costs.

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What I have investigated

4. I have investigated parts a to k of Mr and Mrs Y’s complaint, which concern actions by the Council from May 2019 onwards.
5. In Mr and Mrs Y’s complaint to the Ombudsman, they raised complaints about the adoption process they went through with the Council in 2018. The last section of this decision statement explains my reasons for not investigating this far back.

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The Ombudsman’s role and powers

6. 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)
7. If we are satisfied with a council’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)

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How I considered this complaint

8. I considered the information and documents provided by Mr and Mrs Y, and the Council. I spoke to Mr and Mrs Y about their complaint.
9. Mr Y, Mrs Y and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.
10. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Office for Standards in Education, Children’s Services and Skills (Ofsted), we will share this decision with Ofsted.

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What I found

What should have happened

Safeguarding children

11. Councils have a duty to make enquiries where it has reasonable cause to suspect that a child in its area is suffering, or is likely to suffer, significant harm. The enquiries must establish the child’s situation and enable it to decide whether it should take any action to safeguard or promote the child’s welfare.
12. In carrying out these section 47 duties, the council has the power to call on other bodies to help with its enquiries, including the police and relevant health and education professionals.
13. If, following a referral and an initial assessment by a social worker, a multi-agency strategy meeting decides that the concerns are substantiated and the child is likely to suffer significant harm, the Council will arrange a Child Protection Conference. This should be arranged within 15 working days of the multi-agency strategy meeting.

Child Protection Conferences

14. The Child Protection Conference decides what action is needed to safeguard the child. This may include making a recommendation that the child should be subject to a Child Protection Plan.
15. After the Initial Child Protection Conference, there will be one or more Review Child Protection Conferences to consider progress on action taken to safeguard the child. The Review Conference should also consider whether the Child Protection Plan should be maintained, amended or discontinued.

Complaints about the conduct of those participating in a Child Protection Conference

16. The Chair of the Conference is responsible for the conduct of the meeting. The Chair should be a professional who is independent of operational and/or line management responsibilities for the case. The Chair is usually a representative of the local authority, but could be from another agency such as a health body.
17. However, the Chair is accountable to the Director of Social Services. Complaints about the conduct of the Chair, if separable from a wider complaint about the conduct of the Conference, should go to the Director and then follow the Council’s complaints procedure.
18. In this case, the Somerset County Council considered the complainants’ complaint under its corporate complaints process.
19. The Council decided to appoint an Independent Investigating Officer as part of its stage two complaint response. We would not normally re-investigate matters investigated by the Council in this way unless we considered that the investigation was flawed. However, we may look at whether the Council properly considered the findings and recommendations of the independent investigation. We may also consider whether any injustice has been appropriately remedied.

What happened

The Council’s initial action under section 47 of the Children Act 1989

20. In May 2019, the Council received a safeguarding referral about Mr and Mrs Y daughter, B. This had come from B’s nursery who had noticed some unexplained bruising.
21. Following this, a Council adoption social worker, who had been working with the family, carried out an investigation under section 47 of the Children Act 1989. The Council decided:

• B was considered to be at continued risk of significant harm so an Initial Child Protection Conference would follow. This Conference would also consider the likelihood of B and her two siblings being at any risk of ongoing harm; and
• a joint investigation with the police was not required. This was because the police were not intending to take action against B’s parents or nursery unless the medical assessments had concluded that the injuries were non-accidental.

22. In June, the Council held an Initial Child Protection Conference, where it was decided that B should be the subject of a Child Protection Plan.
23. Later in June, the senior managers in the Council’s Children Social Care team carried out a review of the initial investigation by the Council’s adoption social worker. This was because they were concerned about the position of the police that B’s case did not justify a joint investigation. The Council decided a joint investigation between the police and its Children Social Care team should be completed.
24. A strategy meeting took place that decided the joint investigation should go ahead. It decided this should include: a full investigation of the nursery's actions, contacting all family members who may have had contact with B during the likely timeframe the injury occurred, and an updated Child and Family Assessment to consider any additional support Mr and Mrs Y may need
25. The next day, a Council social worker, jointly with the police, took the following actions:

• visited Mr and Mrs Y’s home to explain a second investigation under section 47 was taking place jointly with the police; and,
• made enquiries with B’s nursery. The social worker and police decided it was not likely the injury to B could have occurred at the nursery without this being observed by others present at the time.

26. At the beginning of July, the Council social worker completed the section 47 enquiries. The outcome of this was that B was considered to be at continuing risk of significant harm and the Child Protection Plan in place was “proportionate to the risks identified” so no further action from the enquiries was required.

The Council’s stage one complaint response

27. In August, Mr and Mrs Y complained to the Council. They said the Chair of the Child Protection Conference had acted in a way that was not independent. They asked for a new Chair to be appointed for the Review Child Protection Conference that was due to take place at the end of August.
28. At beginning of September, the Council’s Review Child Protection Conference took place. The Conference decided to bring B’s Child Protection Plan to an end.
29. At the end of September, the Council sent Mr and Mrs Y its stage one complaint response. It said:

• a new Chair was appointed in advance of the Review meeting;
• it upheld their complaint that the Chair had failed to tell them the Conference could have decided no Child Protection or Child in Need Plan was needed;
• it did not uphold Mr and Mrs Y’s complaint about showing the photos of B’s injuries. It said the Chair had obtained the consent of one parent and this was acceptable practice as there was no expectation both parents’ consent needs to be obtained;
• it did not uphold their complaint that the Chair asked the Conference to consider B’s case separately from her siblings to make sure she was put on a Child Protection Plan. The Council said the Chair had acted in line with Working Together to Safeguard Children (2018), which expects professionals to consider the needs and vulnerabilities of each child on an individual basis; and,
• it had investigated the other parts of their complaint concerning the behaviour of the Chair. The Council explained, as these issues concerned personnel matters, it could not provide details of the outcome of the investigation. It assured Mr and Mrs Y appropriate action would be taken.

The Council’s final complaint response and Independent Investigating Officer’s report

30. In October, Mr and Mrs Y requested a stage two complaint response. They accepted the new Chair was a positive outcome. However, they said they did not think the Council had fully responded to other aspects of their complaint and explained why. They asked for an independent investigation into the handling of the Initial Child Protection Conference by someone who was not connected with the Council. They said:

• the Council had failed to speak with Mr Y before completing its stage one response, but only spoke with Mrs Y. They questioned why this was and said they thought this may because of the difference in job roles, which may suggest to the Council Mrs Y would be more compliant;
• the Council response was only addressed to Mrs Y, which suggested unfair treatment of Mr Y by implying it is usual women who are responsible for childcare and omitting him from the process;
• the conduct of the Chair had a significant impact on the outcome of the Initial Child Protection Conference and so was deserving of further consideration beyond any action taken by the Council in its capacity as employer;
• the Chair’s failure to provide all three possible outcomes suggested the Conference was flawed and not independent from the beginning. They said no other professional challenged the Chair’s position on this, which suggested they did not feel free to speak on such matters;
• Ms Y felt intimidated by the Chair when asked about showing the photos of B’s injuries. They say she was not in a position to given considered consent; and,
• they were concerned they were treated in a discriminatory manner because they were adoptive parents.

31. The Council officer replied to Mr and Mrs Y to acknowledge their stage two request and provide details of the Independent Investigating Officer (IIO). The Council officer apologised to Mr and Mrs Y for only naming Mrs Y in the Council’s stage one complaint response.
32. Between November and December, the IIO organised a suitable meeting time and agreed a statement of complaint with Mr and Mrs Y.
33. The IIO and Mr and Mrs Y discussed their complaint in mid-December. Following the discussion, the IIO sent Mr and Mrs Y a copy of her record of this and asked them to confirm whether it was accurate.
34. In mid-January 2020, Mr and Mrs Y replied to the IIO accepting her record of the discussion and providing additional comments.
35. Towards the end of February 2020, the IIO sent the Council her report, which was investigated in the same way as a stage two formal investigation under the Children Act 1989 statutory complaints process.
36. A week later in March, the Council sent Mr and Mrs it stage two adjudication letter and a copy of the IIO’s report. The Council said it agreed with the all finds of the IIO except two where the Council decided to uphold Mr and Mrs Y’s complaints instead of finding it could not make a decision or no decision was made.
37. In August, Mr and Mrs Y complained to the Ombudsman.

Analysis – was there fault by the Council causing injustice?

Independence of the Chair of the Initial Child Protection Conference

38. Mr and Mrs Y complain the Chair of the Initial Child Protection Conference was not independent and seemed to have a view from the beginning about the outcome she wished to achieve. For example, the Chair asked social work representatives twice whether the threshold for a Child Protection Plan had been reached (part a of their complaint).
39. The IIO explained that she had interviewed the Chair of the Conference on this point who said the following:

• prior to the Conference, the Chair had already formed the view that B would need to be placed on a Child Protection Plan. She had recorded on B’s file that, if the majority view of the Conference was that B should be placed on a Child in Need Plan then she would overrule this decision; and
• this decision was, in part, based on the fact she was concerned the Children and Family Assessment had been completed by a social worker without safeguarding experience and the risk to B had been underestimated. However, she said she would have supported the proposal of a Child in Need Plan if new information had been presented at the Conference to suggest the level of risk to B was lower than she had assessed it to be.

40. The IIO, therefore, decided to uphold this part of Mr and Mrs Y’s complaint as their view that the Chair had already formed an opinion about her preferred outcome of the meeting had been substantiated. The Council accepted the IIO’s findings here. It said the Chair’s opinion must have influence how she facilitated and directed the discussions in the Conference.
41. However, when considering the impact of this fault, the IIO said she found no evidence it affected the outcome of the Conference. This was because the Chair’s role was to facilitate the discussion at the Conference; she did not have the power to overrule the decision made by the professionals involved in recommending the outcome of the Conference.
42. In any case, after interviewing social care and health professionals present at the Conference, the IIO explained in her report that the majority view was that the outcome of the Conference was correct given the unexplained injury to B.
43. Equally, regarding the Chair asking a social care representative twice whether the threshold for a Child Protection Plan had been reached, the IIO report explained that the relevant social work representative had explained the reasons why she found this to be appropriate and confirmed she had not felt directed towards making a specific recommendation.
44. I find the IIO fully investigated whether the Chair’s failure to act independently affected the outcome of the Conference and explained clearly why it had not.
45. However, based on the Council’s adjudication letter to Mr and Mrs Y, the Council says it does not agree with this aspect of the IIO’s findings. It said this is because “the Chair’s role in a conference is to facilitate a balanced and curious discussion between all members of the conference. I find it difficult to believe, in this case, that this could have happened as the Chair’s perspective was clearly influenced by her prior view of what the outcome of the conference should be.”
46. The Council failed to explain how and whether this affected the outcome of the Conference and the majority view that a Child Protection Plan was necessary. It failed to assess the injustice caused to Mr and Mrs Y and how it would remedy this. I find the Council at fault here. This caused Mr and Mrs Y uncertainty, distress and confusion as it was not clear whether the Council considered the decision of the Conference to be flawed. The Chair’s predetermination give rises to an impression of bias and closed-mindedness in the process, which adds to the complainant’s uncertainty.

Conduct of the Chair of the Initial Child Protection Conference

47. Mr and Mrs Y complain the Chair of the Child Protection Conference:

• responded to Mrs Y’s despair with aggressive behaviour (part b of their complaint); and
• created an environment of fear through the way she carried out the Conference (part h of their complaint).

48. The IIO explained in her report why she was unable to reach a decision on this. She said, after interviewing participants at the Conference, there were differing views on who was responsible for difficulties or tensions that arose. However, she highlighted that lessons can be learned by the Council on how to ensure discussions in such Conferences remains focused and amicable even in difficult circumstances.
49. In the Council’s adjudication letter, it said it disagreed with the IIO’s findings and accepted that it was unacceptable that some people at the Conference felt the Chair’s behaviour was aggressive. It acknowledged the Chair should have been “fair, impartial and even handed in their behaviour to all members of the Conference”. The Council told Mr and Mrs Y that it would address this issue within the service.
50. I find the IIO fully investigated this part of Mr and Mrs Y’s complaint. I am satisfied the Council has sufficiently explained why it disagreed with the IIO’s decision. However, I do not find the Council has considered the appropriate way to remedy the injustice Mr and Mrs Y experienced due to the fault accepted by the Council. I find the Chair’s action caused them distress and frustration. I have addressed this in the section below on remedies.

The Chair’s response to questions about other alleged injuries

51. Mr and Mrs Y complain the Chair of the Initial Child Protection Conference failed to respond when Mr and Mrs Y raised concerns about the Chair bringing up other alleged injuries to their daughter, B, that were unsubstantiated, but instead became more aggressive and defensive (part c of their complaint).
52. The IIO explained in her report that the minutes of the Conference and medical report for B’s hospital made no mention of the alleged other injuries. However, she states the nursery mentioned this in its referral to the Council.
53. The IIO decided not to uphold this aspect of Mr and Mrs Y’s complaint. This was because the Conference was expected to consider all concerns raised by the childcare provider and decide the weight to give to these. In the end, the Conference decided not to attach any weight to the alleged other injuries as the medical report mentioned no other significant mark or injury. The other alleged injuries, therefore, did not have any impact on the decision to place B on a Child Protection Plan. The Council agreed with the IIO’s finding of no fault.
54. I do not find this part of the IIO’s investigation flawed as I consider the IIO fully investigated this aspect of Mr and Mrs Y’s complaint. The IIO report sufficiently explained the reasons why the alleged other injuries needed to be considered at the Conference. The Council considered this and accepted the IIO’s findings.
55. I find paragraphs 47 to 50 above sufficiently explain my decision regarding Mr and Mrs Y’s complaint about the Chair’s behaviour.

The Chair’s explanation of possible outcomes of the Conference

56. Mr and Mrs Y complain the Chair of the Initial Child Protection Conference incorrectly told Mr and Mrs Y there were only two possible outcomes of the Conference when there were three. They complain other professionals present failed to correct the Chair (part d of their complaint).
57. The IIO stated in her report that she was unable to reach a decision on the part of Mr and Mrs Y’s complaint concerning the Chair stating there were only two possible outcomes. This was based on the following:
1. the IIO said there are three possible outcomes of the Conference: a Child Protection Plan, a Child in Need Plan if agreement with the parents is achieved, or, if the threshold for a Child Protection Plan is not met and the parents refuse to engage in a Child in Need Plan, then there would be a third possible outcome of no Plan for the child;
2. However, the Council’s Safeguarding Children Partnership manual (from November 2018) provided guidance on outcomes at Child Protection Conferences that suggested there were only two outcomes: either a Child Protection Plan or Child in Need Plan would be put in place. The IIO explained the Chair, therefore, could not be said to have been at fault for following the Council’s guidance.
58. As a result of the IIO findings summarised in point b above, the IIO did not uphold Mr and Mrs Y’s complaint that other professionals were at fault for no correcting the Chair on the number of possible outcomes. This was because the Chair had acted in accordance with the Council’s Safeguarding Children Partnership manual (from November 2018).
59. The Council agreed with the IIO’s findings in its adjudication letter to Mr and Mrs Y.
60. However, in response to questions I raised with the Council, it said it now upholds this aspect of Mr and Mrs Y’s complaint because there are three possible outcomes. It provided details of its guidance to staff on Child Protection Conferences, which states the circumstances in which no Plan may be a suitable option. The Council said it communicated this point to the Chair of the Initial Child Protection Conference.
61. However, based on the evidence I have seen, the Council did not communicate this finding of fault to Mr and Mrs Y nor did it assess the injustice they experienced as a result. This is fault. The Council should have considered the injustice Mr and Mrs Y experienced to decide on a suitable way to remedy this. Mr and Mrs Y experienced uncertainty and missed out on understanding why the Initial Child Protection Plan would not have led to the outcome of no Plan when a Child Protection Plan was deemed necessary.

The Chair’s sharing of photographs of the alleged injury

62. Mr and Mrs Y complain the Chair of the Child Protection Conference shared photographs of the alleged injury to B outside of the Conference when one parent was not present and despite saying the investigating social worker should not have taken the photograph (part e of their complaint).
63. The IIO said in her report that, during an interview, the Chair of the Conference explained she had requested Mrs Y’s permission to show Mrs Y’s father photos of the alleged injury. However, the Chair agreed that, during the Conference, she stated social workers should not take photos of injuries and only medical professionals should do so. The IIO found this to be fault, which the Council accepted. The IIO report said this situation caused Mr and Mrs Y confusion as they were aware the photos of the alleged injury had been taken by a social worker and it left them questioning whether the photo showed an accurate representation of the injuries.
64. In response to questions I asked the Council, it said any photo that was shared should have been from medical evidence. This meant the photos of the alleged injuries, which were on a social worker’s phone, did not comply with the Council’s policy about sharing and storing photographs. This is fault, which the Council has accepted. I find that this also caused Mr and Mrs Y understandable, avoidable distress as potentially upsetting photos that should not have been taken were shown to Mrs Y and her father.
65. The IIO recommended the Council develop a clear policy and guidance for staff about when photos should be used as evidence in Child Protection Conferences and who is approved to take photos of injuries.
66. The Council confirmed to Mr and Mrs Y, in April 2021, this guidance already exists and provided details of the guidance. The Council said, because of their experiences, it had reminded staff about the guidance they are expected to follow.

The Chair’s decision to discuss B’s case separately from her siblings’

67. Mr and Mrs Y complain, at the end of the Conference, the Chair of the Initial Child Protection Conference asked for B’s case to be discussed separately to Mr and Mrs Y's other two children, which they say was to make sure B was put on a Child Protection Plan (part f of their complaint).
68. The IIO explained in her report that B’s sibling were considered to be in similar situations during the Conference and so the focus should be on B’s alleged injury. However, the IIO found good practice required that both B’s siblings and their needs should have been considered on an individual basis, like B was. The IIO found one of B’s siblings missed out on an advocate and there was no clear input from the sibling’s school either. The IIO decided to uphold Mr and Mrs Y’s complaint that both siblings were considered as a pair and not individually, which the Council agreed to.
69. I do not find this part of the IIO’s investigation flawed as I consider the IIO fully investigated this aspect of Mr and Mrs Y’s complaint. However, it is not clear how the Council assessed any injustice Mr and Mrs Y experienced based on the IIO’s findings, which is fault. This meant Mr and Mrs Y missed out on the Council considering whether there were any remedies appropriate for any injustice.
70. I find paragraphs 38 to 46 above sufficiently explains my analysis of whether the Conference’s recommendation to make B subject to a Child Protection Plan was influenced by this action of the Chair.

Input from professionals who knew the family

71. Mr and Mrs Y complain the Chair of the Child Protection Conference failed to make sure there was sufficient input from professionals who knew the family well (part g of their complaint).
72. The IIO explained in her report that she had interviewed professionals involved in the Initial Child Protection Conference. She said none of the professionals, including the adoption social worker who had worked with the family, said they were unable to state their views. The IIO, therefore, did not uphold this part of Mr and Mrs Y’s complaint.
73. I do not find this part of the IIO’s investigation flawed as I consider the IIO fully investigated this aspect of Mr and Mrs Y’s complaint. I find the Council explained in its stage two adjudication letter that it agreed with the IIO’s findings.

The Council’s stage one complaint response

74. Mr and Mrs Y complain that the Council made enquiries that informed its stage one complaint response without involving Mr Y (part i of their complaint).
75. The IIO upheld this part of Mr and Mrs Y’s complaint. The IIO explained she had interviewed the officer responsible for carrying out the stage one investigation who had said, when she called Mrs Y to clarify a few points, she should have checked whether Mrs Y was speaking on behalf of both parties. The Council agreed with this finding of fault. It agreed the stage one investigating officer would formally apologise to Mr and Mrs Y for not seeking Mr Y’s views.
76. I find the IIO fully investigated this point. The Council accepted the fault and agreed to a suitable remedy for the missed opportunity Mr Y experienced in not being fully included in the stage one investigation.

Treatment of the complainants by the Council

77. Mr and Mrs Y complain that the Council treated them differently to other parents because of their professions and being local adoptive parents (part j of their complaint).
78. The IIO said in her report that the professionals she spoke with, who had been involved in the Initial Child Protection Conference, had said they were aware Mr and Mrs Y were professionals and adopters. The IIO said the Conference participants, involved in making the outcome recommendation, accepted it was not usual for parents to be professionals and adoptive parents. However, she said: “Rather than applying higher standards as Mr and Mr Y seemed to feel they had, [the participants of the Conference] were conscious of not being influenced by the parent’s background into not considering the correct level of risk.” She said, given this consideration, it would have been helpful to have acknowledged during the Initial Child Protection Conference that it was likely Mr and Mrs Y were used to looking at safeguarding issues through their professions and this was a difficult process, but the focus was on their children and their welfare.
79. I find, as the IIO suggested in her report, this approach could have helped reassure Mr and Mrs Y that they were not receiving unfair or different treatment because of their professions and being local adoptive parents.
80. However, I do not find that this amounts to fault. The Council taking steps to ensure it was not affected by any unconscious bias is good practice. I, therefore, do not agree with the Council’s finding that a decision cannot be made on this point.

Information from the Council about the second investigation

81. Mr and Mrs Y complain that the Council failed to explain why the Council considered a second investigation was necessary (under section 47 of the Children Act 1989) (part k of their complaint).
82. The IIO explained in her report that a second section 47 enquiry took place for the following reasons:

• senior managers in the Council’s Children’s Social Care team had received an enquiry from Ofsted asking whether the Council’s Local Authority Designated Officer (LADO) had notified Ofsted of the concerns in a timely way. The senior managers reviewed the file and were concerned the first investigation had not been a joint investigation with the police; and
• senior managers decided the section 47 enquiry should be reconvened and carried out jointly with the police.

83. Based on the IIO’s report and the record of the Outcome of the second section 47 enquiry, I find this second investigation was carried out to remedy the fault identified by the senior managers in the initial section 47 enquiry.
84. The IIO upheld this aspect of Mr and Mrs Y’s complaint as she said they had not been provided with clear reasons why the second investigation took place. The Council agreed with this finding of fault in its stage two adjudication letter.
85. This fault caused Mr and Mrs Y distress and confusion about why the were going through a second investigation. The Council should have clearly assessed this injustice caused in its adjudication letter to Mr and Mrs Y. However, it did not do so until April 2021 when the Council wrote to Mr and Mrs Y to apologise for the handling of the initial section 47 investigation. It explained why senior managers intervened. This failure to provide a timely apology in acknowledgment of the injustice experienced is fault. It created a further period of uncertainty for Mr and Mrs Y, including about whether the Council had fully listened to the impact of the fault on them.
86. In response to questions I asked the Council, it said a joint visit with the police and a social worker took place following the senior managers’ decision. However, records of this meeting do not show Mr and Mrs Y were told about the reasons for the second investigation. Based on the evidence I have seen, Mr and Mrs Y were not sent a decision letter either following this meeting explaining the reasons why a second investigation was taking place. Indeed, the Council confirmed a decision letter was not sent to Mr and Mrs Y following the initial Child and Family Assessment. This is fault. This caused Mr and Mrs Y uncertainty and distress due to a lack of clear information about why the Council had taken certain actions.

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Agreed action

87. I have seen evidence that shows the Council has already taken the following action to remedy certain personal injustice experienced by Mr and Mrs Y:

• accepted Mr and Mrs Y’s request for a new Chair to be appointed in advance of the Review Conference. In October 2020, when Mr and Mrs Y requested a stage two complaint response, they told the Council the new Chair was a positive outcome;
• the stage one investigating officer wrote to Mr and Mrs Y to apologise for failing to refer to Mr Y in her stage one response and only speaking with Mrs Y (part i of the complaint);
• in April 2021, the Council wrote to Mr and Mrs Y to apologise for the handling of the initial handling of the section 47 investigation and provided reasons why seniors managers intervened to ensure a full and fair joint investigation was carried out (part k of the complaint); and,
• in April 2021, the Council wrote to Mr and Mrs Y for failing to be clear about all three potential outcomes of the Initial Child Protection Conference (part d of the complaint).

88. I am satisfied the above action remedies some of the injustice experienced by Mr and Mrs Y. However, I do not find it fully remedies the injustice they have experienced.
89. Within four weeks of my final decision, the Council, therefore, has agreed to:
1. apologise in writing to Mr and Mrs Y for the avoidable distress, uncertainty and confusion caused by the fault identified above in relation to parts a, b, e, f and h of their complaint;
2. place a copy of our decision on the family’s file and/or comments from the parents to explain the impact on them. This is because, based on the information I have seen, it is likely, on balance, that the Council’s failure to fully assess the injustice Mr and Mrs Y experienced in its adjudication letter, and the significant delay in the Council apologising (until April 2021), contributed to their feeling of not being heard;
3. make a payment to Mr and Mrs Y of £500 for the significant avoidable distress and uncertainty caused by the fault identified. When recommending this payment I have considered the Ombudsman’s published guidance on remedies. This recommendation is above the Ombudsman’s usual range of £100 to £300. This is because I have factored in the distress caused to two individuals, which was particularly significant due to them missing out on having a Chair that was fair and independent, and having to go through a second section 47 enquiry due to faults in the first one; and,
4. make a payment of £400 to Mr and Mrs Y towards the £1200 legal fees they incurred.
90. The Ombudsman does not recommend that councils reimburse complainants’ legal fees as a matter of course, as complaints procedures, as well as section 47 enquiry and Child Protection Conference processes, do not generally require legal representation to negotiate. However, we can recommend that people receive financial remedies for legal fees if we decide, on balance, the evidence shows it was necessary for them to instruct a solicitor.
91. It is quite exceptional for a council to accept that the Chair of a Child Protection Conference did not act independently and had already formed a view about the outcome of the Conference before it had taken place. This, combined with the lack of clarity and information provided to Mr and Mrs Y about why a second 47 enquiry took place, are the reasons why, in my view, Mr and Mrs Y’s use of legal representation following the Initial Child Protection Conference was justified. I have, therefore, recommended the Council makes a contribution towards the legal fees incurred.
92. The Council has provided evidence of the following service improvements that were made following Mr and Mrs Y’s complaint, which it communicated to Mr and Mrs Y:
1. the Council officer responsible for managing Child Protection Coordinators had emphasised to relevant staff members that they must be clear on the potential outcomes of an Initial Child Protection Conference to ensure families and professionals involved understand these; and
2. the Council reminded staff about its existing guidance to staff on the use of photos in Child Protection Conferences. I have seen evidence of the reminder circulated to all staff about storage of data on mobile phones, which stated social workers should not use phones to take photos of children who are not fully clothed where, for example, they are concerned about a mark or injury. It highlighted such photos should only be taken by appropriate medical staff. I am satisfied the Council has demonstrated it has clear guidance to staff on the use of photos and it has taken steps to remind staff of this.
93. However, within three months of my decision, the Council has agreed to make the following service improvements:
1. review potentially similarly affected cases where the same Chair had chaired the Initial Child Protection Conference between January and June 2019. This covers a six month period prior to the Initial Child Protection Conference that is the subject of Mr and Mrs Y’s complaint;
2. review all relevant guidance to staff on possible Child Protection Conference outcomes to ensure guidance on how each of the three possible outcomes should be considered is harmonised. This is because it is unclear, based on the Council’s response to my enquiries and the IIO’s findings, whether all such guidance clearly specifies the three possible outcomes;
3. review it policies on Child Protection Conferences and Section 47 Enquiries under the Children Act 1989 to make sure it is clear to staff when key decisions should be put in writing and/or communicated verbally to the child’s parents/guardians with full reasons for any decision made;
4. review its complaints handling process, particularly regarding Child Protection Conferences, to ensure clear information is given to staff on assessing injustice when fault is found and awarding appropriate remedies for this. The Council should consider including a reference to the Ombudsman’s published guidance on remedies in the guidance; and,
5. share this decision with relevant staff.
94. The Ombudsman will need to see evidence that these actions have been completed.

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Final decision

95. I have completed my investigation. I have decided to uphold parts a, b, d to f, h, i and k of Mr and Mrs Y’s complaint because there was fault causing injustice. The Council has accepted this fault and already taken certain action to remedy this. The above recommendations are suitable ways for the Council to remedy the remaining injustice Mr and Mrs Y have experienced. The Council has agreed to these actions.
96. I have decided not to uphold parts c, g and j of their complaint because there was no fault causing injustice to Mr and Mrs Y.

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Parts of the complaint that I did not investigate

97. In Mr and Mrs Y’s complaint to the Ombudsman, they raised complaints about the adoption process they went through with the Council in 2018.
98. The law says we cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
99. Mr and Mrs Y have explained why they did not complain to the Ombudsman sooner than August 2020 and I have considered their reasons.
100. In Mr and Mrs Y’s case, I think that they could have complained sooner. I, therefore, do not consider there are good reasons to investigate further back than May 2019.

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Investigator's decision on behalf of the Ombudsman