Summary: The Council was at fault for causing a short delay to a child protection conference, and for not initially visiting Miss B’s children as often as it said it would. But, in the context of Miss B’s complaint about how the Council handled her children’s case, the areas of fault were limited. The Council took Miss B’s concerns seriously, fully considered the risk to her children, and followed the safeguarding process set out by the government. Nonetheless, it has agreed to take action to ensure its mistakes are addressed in future.

The complaint

1. The complainant, whom I refer to as Miss B, complains about how the Council managed risk to her children from their father. I refer to their father as Mr C.
2. Miss B says:

1. The Council removed her children from her care and placed them with Mr C, who was a danger to them. He had a history of violence, domestic abuse and sex offences. And before placing the children, their social worker had told
   Miss B that they should not see Mr C because of the risk he posed.
2. The Council then failed to monitor the children’s safety. Mr C continued to use drugs and alcohol, and his house (and the children) were dirty. Miss B provided the Council with evidence of this, but it did not keep the children safe.
3. She repeatedly tried to raise concerns about Mr C with the children’s social worker but felt like she was not listened to. The social worker’s manager failed to ring her back, despite numerous requests. And the social worker did not tell her when child protection conferences were being held.
4. She had little contact with the children after they moved in with Mr C.

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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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We consider whether there was fault in the way a council made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. 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)
6. 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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What I have and have not investigated

7. The Council’s social work team is still involved with Miss B’s children. This means some of the issues she raises are likely ongoing.
8. The Ombudsman cannot make operational decisions on a council’s behalf, so I will not comment on any events which have taken place very recently or are likely to take place in the near future.
9. With this in mind, I will end my investigation in mid-January 2024, when the Council wrote to Miss B with its final response to her complaint.
10. If Miss B wants to make a new complaint about anything which has happened since then, she should do so to the Council directly.

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How I considered this complaint

11. I considered:
• Information from Miss B and the Council, including Miss B’s children’s social care records.
• The statutory guidance on child safeguarding, ‘Working together to safeguard children’.
• Regional safeguarding procedures for the Council’s area.
12. Miss 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 I found

The Council’s responsibilities

13. Councils have specific safeguarding duties to children. Unless otherwise stated, these duties (summarised below) are set out in the statutory guidance.
14. If a council suspects a child is likely to suffer significant harm, it has a duty to decide whether to take any safeguarding action. This duty falls under section 47 of the Children Act 1989.
15. In such cases, the council should – within three working days of becoming concerned about the significant harm (Regional procedures) – hold a strategy discussion with other relevant agencies (such as the Police). This discussion will be used to share information and decide whether a safeguarding investigation (routinely referred to as a ‘section 47’) is needed.
16. Although other agencies help, councils lead section 47 investigations, and are responsible for deciding what action to take afterwards. If the council still suspects the child may be suffering significant harm, it must arrange an initial child protection conference. This must take place within 15 working days of the strategy discussion. (Regional procedures)
17. The initial child protection conference brings together family members with the professionals involved with the child. The conference decides whether the risk of harm is such that a child protection plan should be formed.
18. The aim of a child protection plan is to ensure the child is safe. It will also, if appropriate, support the family to ensure the child’s safety. The frequency of social work visits must be decided in the plan. (Regional procedures)
19. The multi-agency group which co-ordinates the child protection plan is known as the ‘core group’. The first core group meeting should be held within 10 days of the initial child protection conference, the second should be six weeks later, and thereafter the group should meet at least every two months. (Regional procedures)
20. The core group can review the frequency of social work visits (Regional procedures). Any changes must be recorded in the child protection plan and verified by a Service Manager. (The Council’s core group pro forma)
21. Review child protection conferences should consider whether the child is still likely to suffer significant harm. If they are not, they should no longer be the subject of a child protection plan.

What happened

Before the move

22. In June 2022, the Council’s social work team began supporting Miss B’s children because of concerns about domestic abuse between Miss B and her partner.
23. The Council completed an assessment in August. It noted that Miss B had chosen to stop the children’s contact with Mr C. It made no comment on this.
24. In November, Miss B told the Council that she and her partner used drugs and needed help. The Council decided to hold a strategy discussion.
25. This took place in early December. Different agencies raised concerns about
    Miss B’s care of the children, including domestic abuse, mental health issues and substance misuse. The Council decided to start a section 47 investigation.
26. After two home visits, which significantly increased the Council’s concerns about the children’s safety, Miss B agreed that they needed to stay somewhere else.
27. At Miss B’s request, the Council contacted certain people, including her mother and an ex-partner. But none of them could help. So Miss B suggested Mr C, and said she was happy for the children to stay with him for the weekend.
28. The Council noted concerns about Mr C, including a history of domestic abuse. But it formed a written agreement which set out its expectations of him. It also spoke to the children and checked the condition of his flat.
29. The Council then took the children to Mr C and arranged a check-up visit for over the weekend. He also agreed to take part in a risk assessment.

Immediately after the move

30. In the days following the children’s move, Mr C told the Council that – as he had parental responsibility for them – he wanted them to stay. The Council visited more than once and had no concerns.
31. Miss B, however, was unhappy with the arrangement. She said Mr C was an unsuitable carer because of his history of violence and sex offences. The Council asked her to meet the social worker to discuss her concerns. She did not do so. But she did ask to speak to the social worker’s manager, who did not respond.
32. Just before Christmas, the Council completed its section 47 investigation. It decided to arrange a child protection conference.
33. The Council sought, and received, information about Mr C’s history from another agency. And it also started its risk assessment of Mr C.
34. In early January, just before the child protection conference, the Council visited Mr C and had concerns about his behaviour. He agreed for the children to stay with a family member.
35. The Council held a meeting with him the following day, in which it reiterated its expectations of him. The children returned to his care.
36. The child protection conference agreed the children should be made subject to a child protection plan. Among other things, the plan involved daily visits from the children’s social worker.
37. The conference Chair tried to contact Miss B but was unsuccessful.

The child protection plan

38. In the fortnight after the conference, the Council visited the children three times.
39. The Council then held a core group meeting. The group noted its pre-existing concerns about Mr C, but also said he had engaged with the risk assessment.
40. The social worker told the group that Miss B appeared to still be using heroin and was still in an abusive relationship. She had also refused to attend a meeting with the social worker and had refused to pass on any more of the children’s things.
41. The meeting record says the frequency of social work visits changed from daily to every three weeks. There was no reason for this, and no management approval.
42. After the meeting, the social worker spoke to Miss B, who said she had not contacted the children since their move to Mr C’s and had not told them she had a new telephone number. The social worker offered to arrange contact sessions, but not with Miss B’s boyfriend present. Miss B said she did not understand this.
43. The Council visited the children twice in February and had no concerns.
44. It was Miss B’s youngest child’s birthday at the end of February. She did not contact him.
45. In March, Miss B told the Council that Mr C was in a relationship with his former partner (to whom he had been violent). The Council formed a new agreement saying he would not have contact with her, which he signed.
46. The Council visited the children several times and held another core group meeting but had no other concerns.
47. The Council held a review child protection conference – which Miss B attended – at the end of March. The attendees noted positive changes to the children’s lives. Social work visits remained at every three weeks.
48. In April, the Council supervised contact between Miss B and the children, which went well. From this point on, contact was supervised by Miss B’s mother.
49. After this, Miss B asked to speak to a manager. She repeated concerns she had raised about Mr C previously. The manager did not get back to her.
     
50. Miss B also reported Mr C to the Police for being abusive to her by text message. The Police reviewed the text message evidence but took no further action.
51. The Council visited the children five times over May and June and held two core group meetings, but it raised no issues with their care.
52. In July, after hearing about concerns for the children, the Council visited their home, spoke to one of them on the telephone, and noted improvements which had been made since the concerns were raised.
53. The Council then did further work with Mr C and visited the house unannounced in August and September. The core group following this had no concerns.
54. The Council held the second review child protection conference at the end of September. The attendees unanimously decided the children were no longer at risk of significant harm.
55. The meeting record also says Miss B had not contacted the children or the Council for some time.
56. The child protection plan ended, but the Council agreed to continue supporting the children.

After the child protection plan

57. In the period up to the Council’s final response to Miss B’s complaint in January 2024, the Council sought information from other agencies, visited the children and reviewed their support plan. But it had no new concerns.
58. The Council’s manager finally met with Miss B in February to discuss her concerns.

My findings

Complaint A: The move to Mr C’s home

59. The Council acted in line with its statutory duties when it became aware of the risk to Miss B’s children in late 2022. It held a strategy meeting with all the relevant agencies, did a section 47 investigation and held a child protection conference.
60. There were short delays to the strategy discussion and the conference, though, which meant the child protection plan was not agreed until mid-January 2023 (when it should have been in place by Christmas).
61. I have seen no good reason for these delays, so I have found fault with the Council.
62. However, this did not cause any injustice to Miss B or her children. The Council was clearly taking safeguarding action to protect the children irrespective of when the child protection plan came into force.
63. It is worth noting that Miss B herself suggested that the children go and stay with Mr C for the weekend. And, as he had parental responsibility for them, he could have arranged for them to live with him anyway. There is no evidence that the Council had previously said he should not have any contact with them.
64. Nonetheless, the Council did make enquiries about other people who may have been able to help. But nobody could.
65. Despite the Council’s concerns about the risk from Mr C, it still agreed not to prevent them going into his care. But before this happened, it:
• Sought the children’s views.
   
• Visited Mr C’s home to assess its suitability.
• Formed a written agreement with him, setting out its expectations.
• Sought information from other agencies about his history.
• Began a risk assessment.
• Arranged a visit over the weekend by its out of hours team.
• Continued its safeguarding process, which resulted in the child protection plan.
66. As the Council clearly recorded its concerns and took reasonable steps to mitigate those concerns, I am satisfied that there was no obvious fault in how it acted when the children moved into Mr C’s care.
67. This, then, was a matter of professional judgment, which I have no power to question.

Complaint B: Living with Mr C

68. Although Miss B continued to raise concerns about Mr C after the children moved into his care, I do not agree that the Council failed to take action to protect them.
69. The Council clearly explained its expectations of Mr C, firstly in the working agreement, and then in the child protection plan.
70. The plan set out several ways in which the Council was to ensure the children’s safety. And it was reviewed regularly. This all happened in the way it should have.
71. The Council also reacted to events, amended its expectations of Mr C when it felt this was necessary, and continued to ensure the risk was considered in a multi-agency setting.
72. However, one of the ways in which the Council was initially supposed to monitor the children was by daily visits to see them. And – although there were three home visits between the initial child protection conference and the first core group – these were not as frequent as they should have been.
73. Furthermore, at the first core group the visiting frequency was changed to every three weeks. But there was no explanation why the Council considered the risk to have reduced so significantly in such a short period, and the change was not agreed by a service manager, as it should have been.
74. It is not for me to say that the risks to the children justified a certain frequency of home visits. And it is true that, over the course of the child protection plan, the children’s social worker visited them consistently and, it appears, effectively.
75. But the Council itself decided daily visits were needed at the start of the child protection plan, and it was at fault for failing to meet this commitment.
76. As with the delays to the strategy discussion and the initial child protection conference, this matter did not cause any injustice to Miss B or her children.
77. However, it is not difficult to imagine that, in a different case, similar failings in oversight could potentially have serious consequences. The Council should take measures to ensure this does not happen again.

Complaint C: Communication

78. On the whole, the Council’s communication with Miss B was satisfactory. Her children’s social worker was responsive to her by telephone and text message, and there is no evidence that the social worker failed to give her important information at any point.
79. A significant issue was that Miss B regularly spent time out of contact either with the Council or with her children. She also regularly changed her telephone number, refused to attend meetings, failed to answer the telephone, and asked that very complex information was relayed by text message.
80. This was reflected in her attendance at child protection conferences. She went to one, but the Council could not contact her before the other two.
81. This was not the Council’s fault.
82. However, Miss B asked to speak to a manager more than once over the period of a year and received no response, for which the Council was at fault.
83. This does not mean she was trying to contact a manager for a full year. There were periods when she was not communicating with the Council at all.
84. The Council’s manager has now met with Miss B to discuss her concerns. Consequently, the Council has resolved her injustice and no further action is needed.

Complaint D: Family contact

85. There were no obvious failings in the way the Council handled contact between Miss B and her children.
86. The Council initially supervised the contact, and then left it to the children and Miss B herself to arrange visits (with supervision from Miss B’s mother).
87. There is evidence that Miss B herself failed to get in contact with the children for long periods of time, including over her youngest child’s birthday. But this was outside the Council’s control.
88. Consequently, I have found no fault with the Council on this point.

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Agreed action

89. Within two months, the Council has agreed to provide us with an action plan which sets out how, in future, it will avoid similar failings in safeguarding timeliness and social work visiting frequency.
90. The Council will provide us with evidence it has done these things.

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Final decision

91. There was some fault in how the Council took action to protect Miss B’s children; however, in the context of Miss B’s complaint, this fault was quite limited.

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Investigator's decision on behalf of the Ombudsman