Summary: Miss X complains about the way the Council has dealt with abuse and harm she suffered while she was a Looked After Child in the Council’s care. Miss X feels the Council downplayed and belittled the harm she had experienced. The Council’s handling of Miss X’s complaints has been flawed and unnecessarily delayed. The Council has agreed to apologise, make a further payment and provide Miss X with details of the action it has taken to improve its service. The Council will also issue reminders and training to relevant staff.

The complaint

1. Miss X complains about the way the Council has dealt with her complaints about abuse and harm she suffered while she was a Looked After Child in the Council’s care. Miss X says the Council has:

• downplayed and belittled the harm she experienced as a child in its care;
• used unprofessional and inappropriate language (for example calling her a naughty child) when referring to things that happened to her as a child;
• failed to accept or acknowledge the physical abuse and harm she experienced on at least seven occasions whilst in the Council’s care; and,
• failed to provide suitable outcomes and remedies following the complaints investigation into her concerns, including not providing an appropriate financial remedy or evidence the Council has completed the service improvement recommendations.

Miss X says this continues to cause significant distress as she feels the Council has not taken her concerns nor the impact on her seriously.

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The Ombudsman’s role and powers

2. 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)
3. 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)

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How I considered this complaint

4. I have spoken to Miss X and considered the information she has provided in support of her concerns.
5. I have considered the information the Council has provided in response to my enquiries.
6. 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.
7. Miss X 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 I found

Relevant legal and administrative guidance

Council duties to looked after children

8. A Looked after Child is any child who is subject to a care order or accommodated away from their family by a council. The accommodation can be voluntary or by care order. The child becomes looked after when the council has accommodated them for a continuous period of longer than 24 hours. (Children Act 1989, section 20)
9. Councils have a general duty when looking after a child to safeguard and promote the welfare of the child. This duty underpins all activity by the council in relation to looked after children. This duty has become known as ‘corporate parenting’. In simple terms, ‘corporate parenting’ means the collective responsibility of the council, elected members, employees, and partner agencies, for providing the best possible care and safeguarding for the children who are looked after by the council. (Children Act 1989, section 22 and Applying corporate parenting principles to looked after children and care leavers Statutory Guidance 2018)

Safeguarding children

10. If a council receives a report of concern about a child, it must decide what response is required. This includes determining whether:

• the child requires immediate protection under section 47 of the Children Act 1989; or
• the child is in need and should be assessed under section 17 of the Children Act 1989; or
• there is reasonable cause to suspect that the child is suffering, or likely to suffer, significant harm.

11. The Council’s Childrens Safeguarding procedures define abuse as –

“A form of maltreatment of a child. Somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm. Harm can include ill treatment that is not physical as well as the impact of witnessing ill treatment of others. This can be particularly relevant, for example, in relation to the impact on children of all forms of domestic abuse. Children may be abused in a family or in and institutional or community setting by those known to them, or more rarely, by others. Abuse can take place wholly online, or technology may be used to facilitate offline abuse. Children may be abused by an adult or adults, or another child or children.”

12. Physical abuse is further defined as follows:

“Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child. Physical harm may also be caused when a parent feigns the symptoms of, or deliberately causes, illness in a child. This is known as fabricated or induced illness.

13. Sexual abuse is further defined as follows:

“Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (e.g. rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing.

Sexual abuse includes non-contact activities, such as: involving children in looking at or producing pornographic materials, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse (including via the internet). Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children.

Sexual abuse also includes abuse of children through sexual exploitation. Penetrative sex where one of the partners is under the age of 16 is illegal, although prosecution of similar age, consenting partners is not usual. However, where a child is under the age of 13 it is classified as rape.”

Children’s Social Care Complaints

14. The government sets out a three-stage procedure for councils to follow when looking at complaints about statutory social services. The handling and consideration of complaints consists of three stages. (Department for Education and Skills 2006 Getting the best from complaints: Social Care Complaints and Representations for Children, Young People and Others).
15. Stage 1: Staff at point of service delivery try to resolve the complaint.
16. Stage 2: An investigating officer (IO) and an independent person (IP) investigate the complaint. The IO is responsible for the investigation and the IP ensures the process is open, transparent and fair.
17. The IO writes a stage 2 report which includes:
• details of findings, conclusions and outcomes are against each point of complaint (i.e. “upheld” or “not upheld”); and
• recommendations on how to remedy any injustice to the complainant as appropriate.
18. Once the IO has finished the report, a senior manager should act as Adjudicating Officer (AO) and consider the complaints, the IO’s findings, conclusions, and recommendations, any report from the IP, and the complainant’s desired outcomes. The AO will prepare a response to the reports. In the AO’s response, the complainant should be informed of their right to approach the Ombudsman at any time. (Department for Education and Skills 2006 Getting the best from complaints: Social Care Complaints and Representations for Children, Young People and Others).
19. Stage 3: The complaint is considered by a review panel. The Panel must consist of three independent people (The Children Act 1989 Representations Procedure (England) Regulations 2006 19(2)).
20. The AO should attend as the authority’s representative if they have rejected any of the IO’s findings at stage 2. The complaints manager and anyone providing administrative support should also attend the Panel.
21. Panels should uphold a commitment to objectivity, impartiality and fairness, and ensure that the rights of complainants and all other attendees are respected at all times.
22. Following the panel, the members write a report containing a brief summary of the representations and their recommendations for resolution of the issues (The Children Act 1989 Representations Procedure (England) Regulations 2006 20(1)).
23. The council must send its response to the panel’s recommendations to the complainant within 15 days of receiving the panel’s report. The response should be developed by the relevant Director/Director of Children’s Services setting out how the council will respond to the recommendations and what action will be taken. If the council deviates from the panel’s recommendations it should demonstrate its reasoning in the response. In developing a response, the council should invite comment from all the panel attendees (Department for Education and Skills 2006 Getting the best from complaints: Social Care Complaints and Representations for Children, Young People and Others).
24. The timescales in working days for the procedure are:
• 10 days at stage 1 (with a further 10 days for more complex complaints or additional time if an advocate is required);
• 25 days at stage 2 (with maximum extension to 65 days);
• 20 days for the complainant to request a Review Panel;
• 30 days to meet and hold the Review Panel at stage 3;
• 5 days for the Panel to issue its findings; and,
• 15 days for the council to respond to the findings.

(Department for Education and Skills 2006 Getting the best from complaints: Social Care Complaints and Representations for Children, Young People and Others).

What happened

25. This chronology includes key events and does not include everything that happened.
26. The Council has been involved with Miss X’s family since approximately 2006, following safeguarding concerns raised about her and her siblings while in their parents’ care. In 2010, Miss X and her two siblings were placed on the Council’s child protection register due to physical abuse. Miss X remained in the Council’s care as a Looked After Child from 2010 to 2017, when she moved into supported accommodation as a Care Leaver.
27. On 12 March 2022, Miss X made a complaint to the Council about the way in which had dealt with her as a Looked After Child in its care. The Council wrote to Miss X on 17 March 2022 to explain it would be bypassing stage one of the complaint procedure due to the nature of the complaints Miss X had raised.
28. On 28 March 2022, the Council appointed an Investigating Officer (IO) and Independent Person (IP) to investigate Miss X’s complaints. The IO and IP met with in early April 2022 to discuss and agree her statement of complaint.
29. Miss X’s complaint consisted of the following seven elements:
1. she did not receive her financial entitlement of savings or pocket money during childhood, leaving the Council’s care with no savings;
2. she experienced physical abuse whilst in the Council’s care;
3. she experienced sexual abuse whilst in the Council’s care;
4. she feels she experienced a number of unnecessary placement moves as a child;
5. she feels her placement out of area did not meet her identity needs;
6. she feels she did not received support for her emotional wellbeing despite several requests and was unfairly described as a naughty child; and,
7. when she was approximately two years old, the Council failed to properly investigate concerns her father raised about her and her siblings experiencing abuse and neglect by their mother.
30. The IO completed their stage two investigation report on 16 June 2022 and the IP completed their respective report on 20 June 2022. The IO reached the following conclusions in respect of the above complaint elements:
1. Not upheld – the IO found Miss X had received pocket money as a Looked After Child, but there was limited information on the whereabouts of some savings in Miss X’s name from 2014 onwards.
2. Upheld – the IO found case records relating to seven incidents of Miss X suffering physical abuse, most of which occurred while Miss X absconded from placements. The IO noted the Council’s role to protect a child from harm.
3. Upheld – the IO found case records of incidents of Miss X experiencing sexual abuse on at least three occasions between the ages of 13 and 14 and whilst in the Council’s care. The IO concluded the Council failed to take appropriate action in supporting Miss X to make claims to the Criminal Injuries Compensation Authority (CICA).
4. Upheld – The IO found Miss X experienced a very disruptive history in care, which included 13 different placements. The IO found the Council failed to hold placement sustainability or disruption meetings to consider what steps, if any, it could have taken to prevent placement breakdowns.
5. Upheld – The IO found Miss X was moved to a residential children’s home placement out of the Council’s area in 2014, for a period of at least three and a half years. The IO concluded the Council failed to consider Miss X’s race or culture as a Black female when moving her to a placement in a predominantly White area.
6. Not upheld – The IO found records which showed how the Council and other bodies, such as her school placements, sought to offer Miss X a range of support, including referrals to the NHS’s Child and Adolescent Mental Health Service (CAMHS). The IO concluded Miss X’s turbulent and precarious childhood meant she was unable to engage in the therapeutic services offered.
7. Inconclusive – The IO found no records to show Miss X’s father raised concerns with the Council about her and sibling’s care from their mother.
31. The IO recommended the Council took the following action:

• apologise to Miss X for the upheld elements of her complaint;
• undertake a case review to ensure historic failings are identified and addressed through practice improvements;
• establish procedures for foster carers to set up savings accounts for children in their care;
• to consider financial redress for Miss X for the time, trouble and distress caused in recalling incidents of harm, failing to make a claim to CICA on Miss X’s behalf, the lasting impact of Miss X’s experience whilst in the Council’s care, including stress, inconvenience and hardship.

32. The IP’s report predominantly agreed with the conclusions the IO reached and confirmed their investigation had been thorough and detailed. The IP’s concluded complaint element d listed above should be partially upheld.
33. The Council’s Adjudicating Officer (AO) issued their response to the IO and IP’s reports to Miss X on 5 August 2022. They gave the following views of the IO and IP’s outcomes for each complaint element:
1. The AO agreed with the not upheld outcome reached by the IO and IP.
2. The AO disagreed with the upheld outcome reached by the IO and IP. The AO explained the injury Miss X had sustained when restrained by staff had been unavoidable given Miss X’s challenging behaviour at the time.
3. The AO disagreed with the upheld outcome reached by the IO and IP. The AO explained while they accepted Miss X had experienced sexual abuse, professionals had been unable to minimise the risk of this as Miss X had absconded from placements when the incidents had occurred.
4. The AO agreed with the upheld outcome reached by the IO.
5. The AO disagreed with the upheld outcome reached by the IO and IP. The AO explained the overriding concern was to keep Miss X safe from the risk of Child Sexual Exploitation (CSE) by moving her to a placement outside the Council’s area.
6. The AO agreed with the not upheld outcome reached by the IO and IP.
7. The AO disagreed with the inconclusive outcome reached by the IO and IP. The AO confirmed there were no records of Miss X’s father making a referral to the Council when she was approximately two years old.
34. The AO confirmed the Council would be learning from Miss X’s complaint and experience as a former Looked After Child. They apologised for the fault identified in the IO’s report. The AO also confirmed the Council had recently completed a review of its policy about savings and pocket money for children in care.
35. The AO then commented on the elements the IO recommended be considered for financial redress. The AO explained they did not agree Miss X had been put to additional time and trouble in making her complaint to the Council to warrant financial redress. The AO offered the Council’s support to Miss X if she now wished to make a referral to CICA. The AO offered Miss X a payment of £750 in recognition of the impact of her experiences whilst in the Council’s care. The AO explained the amount of remedy payment offered took account of Miss X’s behaviour as a “significant contributory factor to your negative experiences of being in care”.
36. Miss X remained dissatisfied with the Council’s response and on 16 August 2022, she emailed the Council to ask it to escalate her complaint to stage three panel review.
37. The Council held a virtual stage three review panel hearing on 31 October 2022. Miss X attended, as did the AO, IO, IP and a Council Complaints Officer who acted as note taker for the Panel.
38. The Review Panel considered each of the complaint elements recorded at stage two and asked for Miss X, the IO, the IP and the AOs’ representations and comments for each element. The Review Panel invited the IO, IP and AO to state whether their original outcome for each complaint element had changed based on the representations Miss X had made.
39. The Review Panel held a closed session discussion about the complaint on 2 November 2022. The Review Panel completed its findings report on 7 November 2022. The Panel gave the following views for each element:
1. Partially upheld – The Panel did not uphold Miss X’s complaint about pocket money but did uphold her complaint in respect of her savings. The Panel concluded it had not heard or seen sufficient evidence to demonstrate savings had been paid to Miss X when she left care. The Panel also noted the Council held responsibility for managing Miss X while she was in its care and it had not effectively done so as her corporate parent.
2. Partially upheld – The Panel considered the legal definition of physical abuse. It concluded the incident when Miss X was restrained by staff which caused physical injury, had been in a manner deemed appropriate and proportionate.
3. Upheld – The Panel concluded the Council held responsibility for Miss X’s safety and wellbeing while she was in its care and it had failed to take appropriate action when she had disclosed incidents of sexual abuse.
4. Upheld – The Panel noted the Council had a duty to promote permanency, sustainability and positive outcomes for children ensuring they have safe and secure placements. The Panel concluded this had not been achieved or considered in Miss X’s case through the appropriate process.
5. Upheld – The Panel found there had been no mention in the Council’s records to show it had considered Miss X’s cultural background or heritage when she was moved to a placement outside the Council’s area. This was not in line with guidance for Child in Care reviews or care planning regulations for children.
6. Not upheld – The Panel noted Miss X’s representations during the open session meeting and that she now recognised she had been offered emotional and therapeutic support while in the Council’s care.
7. Not upheld – The Panel noted the IO and IP had changed their outcome from inconclusive to not upheld during the open session meeting, given the lack of evidence to show Miss X’s family had been known to the Council’s Children Social Care Team when she was two years old.
40. The Panel made the following recommendations:

• The Council should reimburse Miss X’s savings last recorded as amounting to £560.
• The Council should update its fostering handbook regarding pocket money and savings to ensure better recording of the amounts being paid and held for children in care, to avoid money not being accounted for and savings being lost.
• The Council should ensure staff caring for children receive training on safe restraint to help prevent unnecessary physical injuries.
• The Council should remind staff about using appropriate language for sexual assault/abuse. In particular, not describing children under the age of consent as ‘sexually active’ as this minimizes the extent of the harm/abuse that has occurred.
• The Council should ensure placement moves are reviewed and considered alongside the Care Planning, Placement and Case Review Regulations 2010.
• The Council should ensure its involvement with children and their families takes account of issues surrounding their identity, such as race, religious beliefs, heritage and culture. This should include raising awareness with the Independent Review Officer (IRO) Service, who are appointed to oversee and scrutinise a child’s care plan.
• The Council should provide Miss X with information about how she can report historical incidents to the police and seek support from the Independent Sexual Violence Advisor.

41. A different Council Adjudicating Officer (AO) issued their response to the Review Panel’s findings report to Miss X on 19 December 2022. The AO confirmed their acceptance with all the outcomes reached by the Review Panel. The AO made an unreserved apology to Miss X for the faults identified by the Review Panel and provided details of the action the Council was taking in respect of the service improvement recommendations made in this case. The AO also provided contact details for the Independent Sexual Violence Advisor and that a payment of £560 representing Miss X’s savings would be made. The AO concluded their response with an additional payment offer of £1,000 to Miss X for the distress caused by the faults identified at stages two and three of the complaint process.
42. Miss X brought her complaint to us shortly after the Council’s stage three response, as she remained dissatisfied with its handling.

Analysis

43. I do not intend to revisit large parts of the stage two complaint investigation or comment on the findings reached in Miss X’s case. Miss X has confirmed to me she was satisfied the IO and IP had conducted a thorough and detailed investigation into her concerns. She says she felt the extent and impact of the harm and trauma she had experienced as a Looked After Child had finally been recognised in the content of the IO’s stage two report.
44. The AO’s response to the IO and IP’s stage two reports had therefore been a shock and distressing for Miss X to read. Having considered the overall tone and content of the AO’s response, I am inclined to agree with her view that this has appeared to downplay and belittle the significant harm Miss X had experienced as a child.
45. The AO’s response failed to acknowledge or accept the Council’s role and duties to Miss X as a Looked After Child, even when she had absconded from placements. The Council failed in its role as Miss X’s corporate parent to protect her from harm and to provide her with, as a minimum, ‘good enough’ parenting. ‘Good enough’ parenting is the standard councils assess parents against and if the Council had removed Miss X from a situation where she was not receiving ‘good enough’ parenting, this is the minimum it should have offered her while in its care. The Council failed to take appropriate action to keep her safe or to ensure offences were reported to the police when it was clear Miss X had reported being exposed to significant physical and sexual harm. Miss X was a vulnerable child who had already experienced significant trauma while in her parents’ care. When she was removed from her mother and placed in the Council’s care, she should have not been exposed to further harm.
46. The AO’s stage two response and the subsequent stage three review appear to focus on considering one incident of physical injury when Miss X was restrained by staff. This overlooks the other six incidents of physical harm Miss X experienced whilst in the Council’s care. There appears no dispute by the Council as its own case records show Miss X reported these incidents at the time. The Council’s failure to acknowledge or consider these incidents has understandably added to Miss X’s feelings that the Council has downplayed and belittled her experiences and the harm caused to her while in the Council’s care.
47. The AO’s comment that the remedy payment offered at stage two had taken account of Miss X’s behaviour as a Looked After Child is also concerning. It implies Miss X’s behaviour was somehow the reason for the harm and trauma she had experienced while in the Council’s care which is wholly inappropriate.
48. Current government guidance explains why victim blaming is harmful:

“Blaming children and young people for their own abuse is never acceptable.

Professionals should clearly understand that children can never be expected to predict, pre-empt or protect themselves from abuse. Irrespective of the context or circumstance, the responsibility always lies with the person who abused the child or young person…

…When victim blaming occurs, there is a risk of diminishing the child or young person’s experiences, leading to a lack of, or an inappropriate, safeguarding response…

…This can have a devasting impact for the child or young person who has experienced abuse and make it less likely that they, or their peers, will have the confidence to disclose abuse in the future. In addition, victim blaming attitudes can prevent families, friends and wider society from recognising certain behaviours as abuse…” (Challenging victim blaming language and behaviours when dealing with the online experiences of children and young people, October 2022)

49. The Council’s handling of Miss X’s complaints at both stages was delayed. It took the Council 100 working days to complete stage two of a process that should take a maximum of 65 working days. The Council then took a further 88 working days to complete stage three, which at a maximum should take 50 working days. Throughout this time, Miss X sent the Council several emails chasing its response. It is clear the Council’s delay caused Miss X unnecessary distress and uncertainty which the Council has failed to appropriately remedy.

Agreed action

50. Within one month of my final decision, the Council agrees to:

• apologise to Miss X for the fault identified in this decision statement. In particular for the injustice caused by not acknowledging the impact and harm Miss X experienced during all seven incidents of physical abuse/assault recorded by the Council while she was in its care. The apology letter should also include details of specific action the Council has taken to improve its services as a result of the recommendations made during the statutory complaint investigation of Miss X’s complaints;
• calculate and offer Miss X the average rate of interest applicable to savings for the period Miss X was a Looked After Child and apply this to the savings already reimbursed;
• make a payment of £1,000 in recognition of the injustice caused to Miss X by the additional faults identified in this decision statement.

51. Within three months of my final decision, the Council agrees to issue a reminder to all relevant staff, including IOs, IPs and stage three panel members to consider, and if needed, recommend remedies to address the impact of delay in the statutory complaint process.
52. Within six months of my final decision, the Council agrees to provide training and guidance to all staff, including IOs, IPs, AOs and stage three panel members, involved in the statutory complaint process on victim blaming, with particular reference to the government guidance issued within the UK Council for Internet Safety – Challenging victim blaming language and behaviours when dealing with the online experiences of children and young people
53. The Council should provide us with evidence it has complied with the above actions.

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Final decision

54. I have completed my investigation and uphold Miss X’s complaint. The actions of the Council caused injustice to Miss X, which it has agreed to remedy with the actions I have proposed.

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Investigator's decision on behalf of the Ombudsman