Summary: Mrs X complains the Council failed to correctly follow child protection procedures, providing inaccurate and unverified information to the Initial Child Protection Conference. She also says the Council did not properly investigate allegations from family members. We have found the Council at fault for the delay in completing the statutory children’s complaints procedure. We have also found the Council acted with fault by not fully addressing the avoidable distress and uncertainty its actions caused Mrs X. We have made recommendations to remedy the injustice caused.

The complaint

1. Mrs X complains the Council failed to follow correct child protection procedures and provided inaccurate or unverified information to the Initial Child Protection Conference. Mrs X says her children were placed on a Child Protection Plan, but says this would not have happened if the Council had followed correct procedures.
2. Mrs X also complains the Council did not properly investigate allegations made by other family members, and did not speak to appropriate individuals as part of this investigation.

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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)

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How I considered this complaint

4. I considered information Mrs X provided and discussed the complaint with her.
5. I considered information the Council provided.
6. Both Mrs X and the Council were able to comment on a draft version of this decision. I considered any comments received before making a final decision.
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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Relevant legislation, guidance and policy

Child protection – Duty to investigate

8. Councils have a duty to investigate if there is reasonable cause to suspect that a child in their area is suffering, or is likely to suffer, significant harm. They must decide whether they should take any action to safeguard or promote the child’s welfare. (Children Act 1989, section 47)

Duty to make enquiries

9. Under section 47 (S47) 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.
10. Councils should act decisively to protect children from abuse and neglect, including starting care proceedings where existing interventions are insufficient.

Child Protection Conference arrangements

11. If, following a referral and an assessment by a social worker, a multi-agency strategy meeting decides the concerns are substantiated and the child is likely to suffer significant harm, the council convenes a Child Protection Conference (CPC).
12. The CPC decides what action is needed to safeguard the child. This might include making the child a ‘child in need’ (CiN) and implementing a safety plan. This may also include a recommendation that the child should be supported by a Child Protection Plan (CPP).
13. After the Initial CPC, there will be one or more Review Child Protection Conferences (RCPCs) to consider progress on action taken to safeguard the child. The Review Conferences will also consider whether to maintain, amend, or discontinue the CPP.
14. RCPCs should be held within three months of the initial conference, and thereafter at maximum intervals of six months.
15. The CPC is a multi-agency body and is not in itself a body in the Ombudsman's jurisdiction.
16. The CPC plays an advisory role. But the final decision, for example whether to place a child on a CPP 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 CPC unless there was good reason not to.

Working Together to Safeguard Children (Working Together 2018)

17. Working Together 2018 is statutory guidance for local authorities and other agencies. It sets out how these agencies should work together to assess children’s needs, and make arrangements for promoting and safeguarding their welfare. It sets out the principles, processes and timescales for carrying out child protection investigations.

The statutory complaints procedure

18. The law sets out a three-stage procedure for councils to follow when looking at complaints about children’s social care services. The accompanying statutory guidance, ‘Getting the Best from Complaints’, explains councils’ responsibilities in more detail.
19. The first stage of the procedure is local resolution. Councils have up to 20 working days to respond.
20. If a complainant is not happy with a council’s stage one response, they can ask that it is considered at stage two. At this stage of the procedure, councils appoint an investigator and an independent person who is responsible for overseeing the investigation. Councils have up to a maximum of 13 weeks to complete stage two of the process from the date of request.
21. If a complainant is unhappy with the outcome of the stage two investigation, they can ask for a stage three review by an independent panel. The council must hold the panel within 30 working days of the date of request, and then issue a final response within 20 working days of the panel hearing.
22. If a council has investigated something under the statutory children’s complaint process, the Ombudsman would not normally re-investigate it unless we consider the investigation was flawed. However, we may look at whether a council properly considered the findings and recommendations of the independent investigation.

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What I found

Background

23. Below is a summary of the key events leading to this investigation. It is not an exhaustive chronology of every exchange between parties. Where necessary, I have expanded on some of these events in the analysis section of this decision statement.
24. Mrs X has two children, referred to in this statement as B and C. Mrs X also fostered her niece, Z.
25. The Council’s stage two investigation report sets out that B has additional needs and displays challenging behaviours. It says B has had a history of engagement with children’s services. The Council’s investigation report says it closed B’s case to children’s social care in September 2020, despite Mrs X stating she still wished for support to continue.
26. In October 2020, Z’s social worker, based in another local authority, learned of an incident between Z and B, which happened in July 2020. Because of this, the Council decided to investigate. The Council asked B to stay elsewhere while it investigated. B moved in with extended family.
27. The Council held a strategy discussion and decided to convene an Initial Child Protection Conference (ICPC). The Council told Mrs X that Z was being removed from her care and placed with alternative foster carers. Later that month, the Council completed a Child and Family Assessment.
28. The ICPC took place in November 2020.
29. In late December 2020, B returned home. The Council visited the family and developed a safety plan.
30. In June 2021, Mrs X complained to the Council about what had happened. Mrs X said:
1. The Council had not told her about the S47 investigation verbally or in writing and had not followed proper procedures.
2. The Council had not considered relevant information and Mrs X had received reports for the ICPC only two hours ahead of the conference taking place.
3. The accuracy of reports the ICPC relied on for its decision were poor.
4. The Council had not provided a social worker specialising in disabilities, despite Mrs X asking for one.
5. She wanted the Council to provide clear, evidence-based reasons for why the family had been placed on a CPP, rather than dealt with under a CiN plan.
31. In July 2021, the Council responded to Mrs X at stage one of its complaints procedure. In its response, the Council:
1. Accepted it had not been clear it was investigating under S47 and apologised for the distress caused by this lack of clarity;
2. Did not uphold the part of Mrs X’s complaint relating to partial information sharing. The Council said parents could not participate in full information sharing in these types of circumstances;
3. Accepted there had been a delay in sharing information with Mrs X ahead of the ICPC taking place, for which it had apologised at the time;
4. Did not uphold the complaint about a lack of disability social worker;
5. Said it understood Mrs X had liaised with the safeguarding unit concerning her disagreement over the outcome of the ICPC, and had received a separate response about this.
32. Mrs X asked the Council to escalate her complaint to the next stage of the complaints procedure. In December 2021, the complaint was allocated to an Investigating Officer (IO) and Independent Person (IP). The Council’s stage two investigation took place from December 2021 to May 2022. On the 13 May 2022, the Council completed its investigation, with the investigation report being compiled on the 23 May 2022. On the 27 June 2022, the Council issued its stage two adjudication letter, setting out its response to the IO and IP’s findings.
33. Mrs X escalated her complaint to stage three of the statutory complaints procedure. The stage three panel review hearing took place on the 3 November 2022, with the panel providing its findings to the Council on the 8 November 2022. On the 29 November 2022, the Council provided its stage three response letter. In its letter, the Council:
1. Apologised for the upset, frustration and distress Mrs X experienced.
2. Set out its consideration of the panel’s findings and recommendations. The Council confirmed it agreed with the panel’s findings and accepted four recommendations the panel made.
3. Offered Mrs X £500 in recognition of the distress caused.
34. Mrs X referred her complaint to the Ombudsman in December 2022.

Analysis

Stage two investigation report – points of complaint and findings

35. The Council’s stage two investigation report identified 11 specific points of complaint. These complaints, and their respective findings, were as follows:
1. The Council had not told Mrs X about the S47 investigation verbally or in writing, and had not followed the correct procedures. This part of the complaint was upheld.
2. The Council did not consider all relevant information for its S47 investigation. Further, the Council accepted information from partner agencies without verifying if it was accurate. This was partially upheld. The Council upheld that it did not consider all the relevant information, and partially upheld that it failed to verify information.
3. The Council had failed to send Mrs X the ICPC conference reports until two hours before the conference took place. This part of the complaint was upheld.
4. The Council had failed to deal with the complaint in a timely manner. This part of the complaint was upheld.
5. Mrs X’s children were managed under a CPP, when Mrs X felt a CiN plan would have been more appropriate. This part of the complaint was not upheld.
6. The ICPC Chair had acted in an unprofessional and patronising manner. This part of the complaint was upheld.
7. Mrs X’s children’s views had not been sought before the ICPC. This part of the complaint was upheld.
8. The Council had failed to invite professionals involved in her children’s wellbeing to the ICPC, or to later conferences. This part of the complaint was partially upheld.
9. The Council did not complete DBS checks for four months, and the checks themselves were unnecessary. This part of the complaint was upheld.
10. The Council failed to put in place a timely rehabilitation plan for B to return home. This part of the complaint was upheld.
11. The Council had failed to investigate allegations made by Mrs X’s sister against their mother’s partner, with the Council completing the assessment without speaking to all of the relevant parties. This part of the complaint was not upheld.
36. The IO, IP and Adjudicating Officer unanimously agreed the findings for each part of the complaint. There were four recommendations, which the Council accepted in full:
1. For the Council to consider developing a policy regarding the use of Barnardo’s workers for ICPCs and gathering the child’s views.
2. For the Council to remind all Chairs to be consistent in recording attempts made by external staff to seek the child’s views.
3. For the Council to consider more effective training for child protection cases of young people living with autism.
4. For the Council to review the findings of the investigation and identify wider learning.

Stage three Review Panel hearing

37. The stage three Review Panel focused on areas that Mrs X remained dissatisfied with. Mrs X was clear the investigators had carried out their role effectively, but said the records contained inaccuracies.
38. The Review Panel changed the findings of the part of Mrs X’s complaint set out in paragraph 35b to fully upheld. It did not change the findings to any other parts of the complaint. The Review Panel made further recommendations, which I have summarised as follows:
1. The Review Panel supported the work already undertaken following the stage two investigation report and recommended that progress be closely monitored.
2. The Review Panel supported an offer made by the Council to meet with Mrs X and carry out a piece of reflective work. This would then be placed on Mrs X’s file.
3. The Review Panel recommended the Council put in place quality assurance systems to improve and monitor response times to complaints.
4. The Review Panel recommended the Council consider a financial remedy in line with the Ombudsman’s guidance. It said this would be to take account of Mrs X’s distress, as well as her time and trouble in dealing with the complaint.
39. In its stage three response letter, the Council accepted the findings and recommendations of the Review Panel in full and offered Mrs X a £500 financial remedy.

Injustice and Remedies

40. The Review Panel said it understood Mrs X’s concerns that the quality of information contained in the S47 reports had far-reaching implications. At stage two of the complaints procedure, the Council accepted there were faults in the S47 process and that information considered at ICPC was incomplete and not fully verified.
41. At stage two of the procedure, the IO stated:

“The IO is of the view it was appropriate at this stage, with the information known to professionals at the time, to manage the safety of the children under a CP plan. The decision for this is a matter for the conference and based on professional judgment. The complaint investigation would not review professional judgment as long as the resulting decisions were taken properly. It is important to stress this as it seems Mrs X is seeking to appeal the decision which cannot be done by making a complaint about it.”

42. The Review Panel stated it also did not have the authority to comment on professional decision-making, within the context of an inter-agency child protection case conference. It said the IO had been correct to confine themselves to consideration of the processes. The Review Panel said it had considered the matter in the same way and had found the processes to have been followed correctly.
43. However, asserting that all processes were followed correctly, while also accepting the S47 enquiries and the information presented to the ICPC were flawed or incomplete, is a contradiction on the Council’s part. It is difficult not to conclude this introduces uncertainty for Mrs X. Mrs X does not know if the ICPC would have recommended the same decision, had the Council not acted with fault in its enquiries and evidence gathering. It is not clear the Council has fully recognised this uncertainty.
44. The Council also accepted that Mrs X had limited opportunity to challenge or correct information contained in these reports, given the delay in the reports being shared with her. Again, it seems contradictory to say processes were followed correctly, when any clarifications or challenges put forward by Mrs X may have been of importance to the ICPC’s decision-making.
45. Mrs X did not understand how the Council could say a CPP was the correct course of action, if all the professionals did not have access to the correct information. The Council did recognise this to an extent in the review panel hearing. However, it said the ICPC considered other information and not just that provided through S47. It said the ICPC considered everything together and decided that a CPP would provide the right level of intervention and support.
46. As set out in paragraph 15, the ICPC is a multi-agency body, not within the Ombudsman’s jurisdiction. This means I cannot judge whether the ICPC recommended the correct decision in Mrs X’s case. I also cannot recommend the ICPC retrospectively change or amend its decision. In this case, all parties agree the ICPC acted properly, based on the information it had to hand.
47. Had the Council properly conducted its S47 enquiries, and properly verified the information submitted, it is possible the ICPC would still have recommended a CPP, based on the other information it considered. It may be that the Council’s faults would have made no difference in this case.
48. However, the Council’s accepted faults have caused Mrs X significant uncertainty, which is an injustice in itself. I do not believe the Council has adequately recognised or addressed this injustice in its complaint response.
49. Further, I believe the Council’s proposed remedy does not fully address the injustice caused by the other faults it has already accepted. The Council fully upheld or partially upheld nine of the 11 parts of Mrs X’s complaint. I believe the wider service improvements proposed were appropriate. However, I believe the personal remedy does not fully recognise the injustice caused not just to Mrs X, but also to B.
50. Mrs X maintained concerns about how the Council had investigated allegations by her sister against her mother’s partner. The Review Panel considered this in detail, as did the IO and IP. The Review Panel did not find cause to change the IO’s findings. It noted there were documents the IO could not fully access, such as a LADO report from another local authority. It said the IO had though had sight of a 72-page connected persons assessment report and was satisfied there had been sufficient information to address this part of the complaint. The IO had been unable to share the details in full with Mrs X, because of data restrictions relating to third-parties, but provided a summary in their report.
51. The Review Panel said:

“We were satisfied that this matter had been thoroughly investigated by the IO. We were further satisfied by the IO’s assurances that, in their view, the allegations referred to within this complaint were fully and properly addressed. Furthermore we were satisfied by the IO’s and IP’s assurances that they considered that the relevant people were spoken to regarding these matters.”

52. I have seen no indication of fault in how this part of Mrs X’s complaint was considered.

Delay

53. Paragraphs 18-22 set out the statutory timescales for councils to conduct the statutory children’s complaints procedure.
54. Mrs X complained to the Council on the 21 June 2021. The Council issued its response on the 20 July 2021, one day beyond the 20 working-day timescale. This is a minor delay, which I would not consider fault. However, the Council’s stage two investigation report suggests there was some confusion around registering complaints from Mrs X at this time. It states:

“Between December 2020 and July 2021, Mrs X’s complaints were not managed in a timely manner and nor were they co-ordinated between the relevant service areas. The complaints guidance requires the local authority to manage and respond to complaints as per the guidance, which did not initially happen in this instance.”

55. There was therefore some unquantified delay at this stage in the process, which the Council accepted.
56. Mrs X asked the Council to escalate her complaint to stage two of the statutory complaints procedure on the 20 July 2021. The Council has 13 weeks to investigate and respond at this stage of the procedure, meaning the Council should have responded by approximately 19 October 2021. It issued its adjudication letter on the 27 June 2022. There was therefore a delay of approximately 37 weeks at stage two of the complaints procedure.
57. Mrs X asked the Council to escalate her complaint to the third stage of the statutory procedure on the 28 June 2022. The Council should have held the review panel no later than the 9 August 2022 and issued its final response no later than the 6 September 2022. The Council held the review panel on the 3 November 2022 and issued its final response on the 29 November 2022. There was therefore a delay of approximately 12 weeks at stage three of the complaints procedure.
58. Taken together, there was a cumulative delay of at least 49 weeks. I have found the Council at fault for these delays. These delays caused Mrs X avoidable frustration and uncertainty, having to expend additional effort to secure a resolution to her complaint.

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Agreed action

59. I have considered the Ombudsman’s published Guidance on Remedies document when making the following recommendations. In particular, I have considered that:
1. The Guidance says where we find faults that have caused distress in the form of uncertainty, we may recommend a payment of up to £500 to recognise that distress. The Guidance says we may recommend more, if the distress was prolonged, affected others, or to take account of the vulnerability of those affected.
2. The Guidance also says in cases where we find there has been delay in completing the statutory complaints procedure, we may recommend a payment of up to £500, depending on the severity of the injustice caused by that delay.
60. Within four weeks of the final decision being issued, the Council has agreed to:
1. Provide a written apology to Mrs X for the faults and injustice identified in this statement. The Council should have regard to the Ombudsman’s guidance on “Making an effective apology", set out in our Guidance on Remedies document.
2. In addition to the other service improvements it has already proposed, the Council should remind officers of the need to complete the children's statutory complaints procedure once started, within the statutory timescales.
3. Pay Mrs X a total of £1150 in recognition of the injustice caused. This is broken down as follows:
1. A total of £750 for the distress and uncertainty arising from the faults identified in this statement. This £750 would include the £500 the Council has already offered Mrs X, if this has not yet been paid.
2. A further £400 to recognise the delay in the statutory complaints procedure.
61. The Council should provide us with evidence it has complied with the above actions.

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Final decision

62. I have completed my investigation with a finding of fault causing injustice. I have made recommendations to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman