Summary: The Council was not at fault for its use of medical evidence when considering the risk to Mrs B’s daughter. However, there was some fault in how the Council dealt with her case. Although it decided she was at risk of significant harm, it failed to arrange a child protection conference, as national guidance says it should have done. This meant the risk was not considered in line with proper procedure. The Council has agreed to take action to recognise Mrs B’s injustice and to improve its service.

The complaint

1. The complainant, whom I refer to as Mrs B, complains about how the Council dealt with a referral about a suspected bruise on her daughter’s leg. I refer to her daughter as C.
2. Mrs B says:
1. The Council ignored any evidence which did not suggest physical abuse. It even suspected Mrs B, although there was no allegation against her.
2. The Council refused to get a dermatologist’s report, despite Mrs B saying a skin condition had caused the mark on C.
3. The Council did not allow her to see her children for a weekend after the referral. And then it failed to clarify continuing childcare arrangements with either her mother (who had looked after the children) or Mrs B herself.
4. The Council decided C was at risk of significant harm but then closed the case without holding a child protection conference.
5. The Council has no record of its decision-making.
3. Mrs B, who is a social worker herself, says she could not work for seven weeks. She also says C’s records say she was at risk of significant harm – something which could affect Mrs B’s future job prospects. And she says she and her children suffered distress.
4. Mrs B wants the Council to reconsider the referral. She also wants an apology and compensation for her loss of income while the Council was conducting its enquiries.

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The Ombudsman’s role and powers

5. 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)
6. We consider whether there was fault in the way a council made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), 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)
8. 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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How I considered this complaint

9. I considered information from Mrs B and the Council.
10. I considered:

• The statutory children’s social work guidance, ‘Working together to safeguard children’.
• The ‘London safeguarding children procedures’.
• The Council’s own children’s social care procedures.

11. Mrs B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What happened

12. In February 2022 the Council received a referral from C’s preschool. It said C had a mark on her leg and had said, “daddy did it”.
13. A social worker spoke to Mrs B, who was unaware of the mark. She reported no concerns about the children’s father (her ex-partner).
14. The social worker spoke to C and her brother at school. C said her father had hit her. She also said he used to hit Mrs B. Her brother made no allegations.
15. The social worker spoke to Mrs B again, who said she was on good terms with her ex-partner, and there had been no domestic abuse. Since last speaking to the social worker, she had seen the mark on C’s leg and believed it was dry skin. The social worker disagreed and said it looked like a bruise.
16. The next day, the Council held a strategy discussion with the Police and the school. It said it would conduct child protection (or ‘section 47’) enquiries to consider the risk to C. The Police decided they would also investigate.
17. A child protection medical assessment took place the next day. The doctor completed a report, which said:

• I asked [C] what happened here and she said to me, in front of mother and the [social worker], “daddy hit me”.
• The large oval lesion … prompting this referral, is most likely a bruise, in my view.
• I am not sure of the significance of the other more diffuse marks on her right upper leg, which are roughly symmetrical to the bruise in location, but different in appearance.
• In short, we have a bruise on [the] upper leg … and a clear allegation from this young clever girl – but so far, there is no more information.

18. The social worker spoke to Mrs B after the medical. She recorded that Mrs B had not properly recognised C’s disclosure of physical abuse (and had tried to find other explanations for the mark).
19. Shortly afterwards, the Council completed its section 47 enquiries. It decided its concerns were substantiated, and C was at risk of significant harm. It said it would complete an assessment and arrange a review strategy meeting. It did not arrange a child protection conference.
20. Mrs B then sought a second medical opinion about the mark on C’s leg; however, the doctor said the mark was inconclusive. The social worker recorded concerns that Mrs B would keep seeking medical opinions until she found the one she wanted, and that this would have a negative impact on C.
21. Mrs B then took C to hospital (after speaking to her GP). A paediatric consultant told C’s social worker that she now had several more marks. The consultant said the hospital would do blood tests, but there was unlikely to be a medical explanation.
22. The social worker recorded concerns that Mrs B may have caused the marks herself to disprove the allegation against her ex-partner. She spoke to Mrs B about these concerns and said there should be a ‘safety plan’ to make sure C and her brother were safe over the weekend.
23. Mrs B suggested that her mother may be able to care for the children. The social worker spoke to Mrs B’s mother, who agreed to have the children until Monday. The social worker said she would ‘follow up’ then. But this did not happen, and the children returned home without any further comment from the Council.
24. The hospital did several blood tests, but they showed nothing unusual.
25. At the end of February – almost three weeks after completing its section 47 enquiries – the Council held a review strategy meeting. The Police decided to take no further action, and the Council decided to offer Mrs B support under a ‘child in need (CIN) plan’.
26. The Council offered this support to Mrs B. She refused.
27. The day after, the social worker spoke to C’s father. She told him the Council’s concerns about the risk of significant harm had been substantiated. He also refused a CIN plan.
28. Later in March, the Council completed its assessment. This said the Council had “concerns that services may be required or the child may be suffering or likely to suffer significant harm due to [physical abuse] by an adult”. But it noted that Mrs B had refused support. The Council agreed to close the case.

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What I found

Complaint A: The Council’s consideration of evidence and concerns about Mrs B

29. The Council did not ignore what Mrs B said about C’s skin condition – in fact, information about this appears regularly throughout C’s records.
30. However, the medical evidence suggested the mark was likely a bruise. And C had made allegations against her father to her preschool, her social worker and a doctor. It was reasonable for the Council to take these allegations seriously.
31. The concerns the Council had about Mrs B’s role in the suspected physical abuse were speculative. But this does not mean the Council was at fault.
32. Councils have a leading role to play in the protection of children. And, if a council becomes aware that a child has an unexplained injury, it must consider how that injury happened, however unpalatable that may be to the child’s parent.
33. Furthermore, I cannot replace a social worker’s professional judgement with my own. Only in exceptional circumstances – when a council’s decision is so obviously unreasonable that it defies logic – can I question it.
34. As the Council’s decision-making was not obviously unreasonable, I have found no fault with how it considered evidence or explored risks to C.

Complaint B: The Council’s refusal to get a dermatologist’s report

35. The medical evidence provided to the Council suggested that the mark on C’s leg was a bruise – rather than, as Mrs B thought, dry skin.
36. It was reasonable for the Council to have relied on this medical evidence, regardless of how much Mrs B disagreed with it. I have found no fault in the Council’s decision not to seek more medical assessments.

Complaint C: The safety plan

37. The Council decided Mrs B’s children should stay with their grandmother for a weekend for their own safety. It said it would ‘follow up’ on the Monday. But it did not do so.
38. This was fault by the Council. And, as the children simply went back to Mrs B three days later without any kind of checks in place, it would be understandable if she wondered why they had to be away from home in the first place.
39. The Council has already apologised for the poor communication. As the fault I have identified is with the lack of follow-up, not the safety plan itself, this is a suitable remedy.

Complaint D: Case closure despite the Council deciding C was at risk of significant harm

Guidance / procedure

40. The statutory guidance says that, if a council conducts section 47 enquiries and decides a child is suffering (or is likely to suffer) significant harm, it should arrange a multi-agency child protection conference.
41. The Chair of the conference should be independent of operational or line management responsibilities for the case. They should meet the child and parents in advance to ensure they understand the process.
42. The regional and local procedures used by the Council do not deviate from the government guidance.

My findings

43. When the Council completed its section 47 enquiries and decided C was at risk of significant harm, it decided the evidence should be considered in a strategy meeting.
44. However, the national guidance and the Council’s own procedures say this should have happened in a child protection conference instead – which, in contrast to a strategy meeting, would have involved an independent Chair and Mrs B herself.
45. This was fault by the Council. And its failure to arrange the conference caused Mrs B an injustice.
46. Firstly, she did not get the opportunity to provide her views on the Council’s concerns directly to a multi-agency conference (or to speak to the Chair). There was also no independent oversight of the case. There is no way of knowing if this would have made a difference to the outcome.
47. Secondly, C’s records say she was at risk of significant harm, but do not make clear that this risk was not considered in line with proper procedure. This has the potential to create a misleading impression to someone reading the records.
48. The Council should take action to remedy Mrs B’s injustice and to ensure similar mistakes do not happen again. I have set out my recommendations in more detail below.

Complaint E: The Council’s records

49. The Council’s records clearly describe the actions it took and the evidence it considered. I have no reason to find fault with its record-keeping.

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Agreed actions

50. Within six weeks, the Council has agreed to:

• Apologise to Mrs B for its failure to arrange a child protection conference to consider the risk to C.
• Make a remedy payment of £250 to Mrs B to recognise that, because it did not arrange the conference, she lost the opportunity to make her case directly to a multi-agency meeting and an independent Chair.
• Attach notes or appendices (or similar) to the case records of C and her brother, highlighting that the risk of significant harm was not considered in line with proper procedure and was not decided by a child protection conference.
• Send us an action plan setting out how it will avoid similar procedural mistakes in risk assessment in future. In doing so, it will consider (among other things) staff training and quality monitoring of cases.
• Provide us with evidence it has done these things.

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Final decision

51. The Council was not at fault for its use of medical evidence when considering the risk to Mrs B’s daughter. However, it was at fault for failing to arrange a child protection conference in line with national guidance.

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Investigator's decision on behalf of the Ombudsman