Summary: Ms X complained about how the Council carried out Child Protection proceedings for her child. There was fault by the Council which caused avoidable distress, time, and trouble for Ms X. The Council agreed to apologise, pay a financial remedy, and place a copy of our decision and the faults identified on its records about Ms X. It will also produce an action plan of how it will avoid recurrence of the same faults and report this action plan to its relevant overview and scrutiny committee for monitoring.

The complaint

1. Ms X complains about how the Council carried out Child Protection proceedings for her child, D, in 2023 and 2024. She says the Council failed to:
• complete the actions set out in the Child Protection Plan;
• properly conduct Child Protection Conferences to update and make decisions about the Plan;
• properly consider her views during the proceedings;
• communicate properly and transparently with her about the proceedings; and
• respond when she complained about these issues.
2. Ms X says the Council caused her distress because of its failings and the prolonged Child Protection proceedings. She wants the Council to properly complete actions in the Child Protection Plan and give the family the help they need.

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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. Service failure can happen when an organisation fails to provide a service as it should have done because of circumstances outside its control. We do not need to show any blame, intent, flawed policy or process, or bad faith by an organisation to say service failure (fault) has occurred. (Local Government Act 1974, sections 26(1), as amended)
5. We consider whether there was fault in the way an organisation 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)
6. The law says we cannot normally investigate a complaint unless we are satisfied the organisation knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the organisation of the complaint and give it an opportunity to investigate and reply. (Local Government Act 1974, section 26(5), section 34(B)6)
7. We cannot investigate a complaint about the start of court action or what happened in court. (Local Government Act 1974, Schedule 5/5A, paragraph 1/3, as amended)
8. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
9. 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

10. I considered:
• information provided by Ms X and discussed the complaint with her;
• documentation and comments from the Council;
• relevant law and guidance; and
• the Ombudsman’s Guidance on Jurisdiction and Guidance on Remedies.
11. Ms X and the Council had opportunity to comment on my draft decision. I considered any comments received before making a final decision.
12. 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 found

Legislation and statutory guidance

Child protection and Section 47 enquiries

13. Where a council has reasonable cause to suspect a child in its 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. It should start such enquiries where there are concerns about abuse or neglect. These enquiries are often called ‘Section 47 enquiries’. (Children Act 1989, section 47)
14. Councils should act decisively to protect children from abuse and neglect including starting care proceedings where existing interventions are insufficient.
15. When making decisions under section 47, the Council should ensure effective partnership working with parents and carers. This means ensuring they understand the process, are provided with relevant information with adequate notice, and are supported to say what they think.

Child Protection Conference arrangements

16. 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 an Initial Child Protection Conference (ICPC). The Child Protection Conference decides what action is needed to safeguard the child. This may include a recommendation that the child should be supported by a Child Protection Plan.
17. After the ICPC, there will be one or more Review Child Protection Conferences (RCPCs) to consider progress on action taken to safeguard the child and whether the Child Protection Plan should be maintained, amended, or discontinued.
18. RCPCs should be held within three months of the initial conference, and thereafter at maximum intervals of six months.
19. Where a council is carrying out section 47 enquiries, it is the duty of certain bodies, including the NHS, to assist with those enquiries when asked to. This means where NHS health representatives are invited to a Child Protection Conference they must attend.
20. The Child Protection Conference is a multi-agency body and is not in itself a body in the Ombudsman's jurisdiction. However, we can investigate the Council’s role as the lead statutory body with responsibility for administering the Conference and liaising with the family.
21. The Child Protection Conference plays an advisory role. But the final decision, for example whether to place a child on a Child Protection Plan 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 Child Protection Conference unless there was good reason not to.

Core group arrangements

22. The statutory guidance on child safeguarding, ‘Working together to safeguard children’, says after the ICPC, the council should convene a core group. This is made up of key family members and professionals involved with the child and/or family.
23. The purpose of core group is to:

• further develop the Child Protection Plan;
• facilitate in-depth assessment to inform decisions about the child’s welfare; and
• implement the Child Protection Plan.

Mental capacity and the Court of Protection

24. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
25. A person aged 16 or over must be presumed to have capacity to make a decision unless it is established they lack capacity.
26. The Court of Protection deals with decision-making for adults who may lack capacity to make specific decisions for themselves. The Court of Protection may need to become involved in particularly difficult cases or cases where there are disagreements that cannot be resolved in any other way. The Court of Protection:

• decides whether a person has capacity to make a particular decision for themselves;
• makes declarations, decisions or orders on financial or welfare matters affecting people who lack capacity to make such decisions;
• appoints deputies to make decisions for people lacking capacity to make those decisions; and
• resolves conflicts about what is in a person’s best interests where they lack capacity.

Background

27. Ms X lives with her child D who was on a Child Protection Plan from September 2020. The Council started court proceedings against Ms X about her care of D in 2021 but withdrew this in 2022, shortly before D turned 16. We have previously considered other complaints from Ms X about older events.
28. In 2023 D was still on a Child Protection Plan, with Review Child Protection Conferences scheduled every six months, and core group meetings every six weeks. In March 2023 the Council decided it should again start court proceedings to apply for an interim care order for D, but again withdrew this in May 2023.
29. Ms X complained to the Council about the child protection proceedings in November and December 2023, then brought her complaint to us in February 2024. We began our investigation in May 2024.
30. In August 2024, D turned 18. At the time of this decision:
• D still lives with Ms X. They have changed from children’s services to adult care services so are no longer on a Child Protection Plan; and
• the Council applied to the Court of Protection in November 2024, for decisions to be made about D’s residence, care and support, and educational provision.

What I have and have not investigated

31. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended). D is now 18, and the Council has applied to the Court of Protection. This means D may lack capacity to make decisions for themselves, and there is a question about who should make decisions for them. D has not given their consent for Ms X to complain to us on their behalf. Therefore, I have only investigated how the Council dealt with Ms X, and whether any fault caused an injustice to Ms X.
32. The Council started court proceedings in March 2023 which it then withdrew in May 2023. We cannot investigate a complaint about the start of court action, so I have not considered this decision by the Council to start court proceedings.
33. The law says the Council must have reasonable opportunity to respond to a complaint before we investigate. When Ms X complained to us, the Council had not issued a complaint response, so we asked it to respond but it failed to do so. In May 2024 we decided the Council had had reasonable opportunity to respond and we should start our investigation. I have therefore considered events from January 2023 to the end of May 2024. However, I have not considered events after the end of May 2024, when we told the Council we would be investigating this complaint.

My findings

Child Protection Conference arrangements

34. There were three Review Child Protection Conferences (RCPCs) in the period I considered, in March 2023, November 2023, and May 2024. I considered whether there was fault by the Council in how it conducted the conferences.
35. The Council rearranged the March 2023 RCPC twice, so it held this seven months after the previous review. This was a delay of one month. The Council provided evidence this delay was because professionals invited from other organisations did not confirm their attendance, and that it chased this once. However, given this concerned a child it had decided was at risk of harm, I do not consider the Council did enough to escalate this and ensure the conference progressed within statutory timescales. The delay was fault.
36. Ms X said she could not attend the March 2023 RCPC after the Council rearranged, because she had no childcare arrangements. However, I found the Council gave Ms X enough notice of the change and told her she could seek support for childcare from its children’s social work team, which she did not. It also sought her views before the conference, and the Chair read these out for consideration.
37. The Council’s child safeguarding procedure says the family should receive reports from professionals five working days before the RCPC. For the March 2023 RCPC, the Council shared late NHS reports with Ms X on the day of the conference. Again, I do not consider the Council did enough, as the lead statutory body administering the RCPC, to chase these reports sooner, or ensure Ms X received them on time and could comment given she would not be attending the RCPC. This was fault.
38. The Council’s child safeguarding procedure says it should bring an RCPC forward when there are new concerns, a change of circumstance with implications for the child’s safety, or significant difficulties in implementing the CP Plan. In June and July 2023 core group meetings, the Council recognised the CP process was not working for D. It had also received new concerns from NHS health professionals in June 2023 about D and risks to their health. However, the Council did not consider whether it should move the September 2023 RCPC earlier. This was fault.
39. After the June 2023 concerns raised by the NHS, the Council asked for a formal health report to inform the CP proceedings. It received this report in September 2023, three days before a scheduled RCPC. It decided it needed more time to consider the implications of the report and risks to D, and how the information should be shared with Ms X, before the next RCPC. It therefore cancelled the meeting and told Ms X this was because it had not received relevant reports within enough time. It discussed the report with health professionals, who then asked for a different version, tailored to Ms X as D’s parent, to be shared with her instead. The Council shared this updated version with Ms X two days after it received the updated version. Ms X queried why the Council had not shared the NHS report with her straight away, and the Council directed her to raise these queries with the NHS, the body that authored the report. Ms X then did complain to the NHS about the report. If Ms X is not satisfied with how the NHS responded to this complaint, she can raise this with the Parliamentary and Health Service Ombudsman (PHSO), which investigates complaints about the NHS. I can only consider how the Council communicated with Ms X about this issue. Although the Council must be transparent with families about CP proceedings, this does not mean it was required to share all its information with Ms X as soon as it received it. Ms X was the subject of child protection concerns so it is correct the Council carefully considered what information it should share with her, and when. In the circumstances I am satisfied the Council was not at fault in how it communicated with Ms X about this.
40. The Council then rearranged the September 2023 RCPC for October, but cancelled this the day before because the Chair was unwell. It then reallocated the case to a new Chair, causing further delay. This meant the RCPC did not happen until November 2023, eight months after the previous review. This was a delay of two months more than statutory timescales, so was fault. However, in the circumstances I consider this fault to be service failure, as described at paragraph 4. The Council properly considered its decisions to cancel and rearrange the RCPC, and this was unavoidable in the circumstances. I found it gave Ms X as much notice as possible.
41. At the May 2024 RCPC, the Council invited an NHS health professional. They did not attend but provided a report for consideration. The Council’s records show it had concerns about a lack of input by health professionals, particularly after June 2023 when its main concern about risk to D came from a report by health professionals. In the circumstances of this case, I do not consider the Council did enough to ensure proper representation from health at the RCPC. This failure to properly address a lack of health engagement with the procedures impacted on the actions in the CP Plan, as I explain further later in this decision statement.

Core group meeting arrangements

42. Ms X often could not attend the core group meetings, but this was not due to fault by the Council. However, the Council still should have ensured Ms X’s views were considered as part of the process even when she could not attend meetings. Ms X provided detailed comments when she received meeting minutes, expressing her concerns about a lack of progress against the actions in the Child Protection Plan. The Council recorded these comments as a late addition to the meeting minutes but there is no evidence it considered them in later meetings or responded to Ms X about her concerns. This was fault.
43. The Council’s child safeguarding procedure says it should hold core group meetings every six weeks. This was also an action on D’s Child Protection Plan. During the delay while the Council considered the NHS report and discussed it with health professionals, it did not arrange any core group meetings. This meant a gap of thirteen weeks where no meetings took place, which was fault.

The Child Protection Plan and completing actions

44. Core group meeting and RCPC minutes throughout the period I considered showed the Council recognised the CP process was not working for D and the CP plan was not progressing. However, it took no meaningful action to address this. As I have already outlined, it did not consider whether it should move RCPCs earlier. At the November 2023 RCPC the Council added a new action to the CP Plan for the social work team to consult with a senior manager about barriers to progression of the Plan. However, no update was provided against this action at the core group meetings that followed from December 2023 to April 2024. At the May 2024 RCPC, the Chair was concerned the CP Plan had not progressed and that Children’s Services needed a robust plan to support D’s upcoming transition to adult services.
45. This lack of progress against the CP Plan was fault, and impacted on some important actions in the Plan as follows.
• Mental Capacity Assessment/ Court of Protection (CoP) application. Following the March 2023 RCPC, the CP Plan included an action for the Council to complete a Mental Capacity Assessment (MCA) for D by September 2023. This action remained in the Plan with no substantive progress made. At the next RCPC in November 2023, D was approaching their 18th birthday. The action to ensure completion of an MCA remained on the Plan, with a new action to seek legal advice about making an application to the Court of Protection. It was only after this review the Council started work to progress this part of the Plan. Its failure to do so from March to November 2023, was fault.
• Health. Following the March 2023 RCPC, the CP Plan included an action for health professionals to complete a chronology of D’s involvement with health services for consideration via CP proceedings. This action was complete by the proposed September 2023 deadline, and the Council received the chronology. However, after this the health actions in the Plan continued to roll over with no progress made. At a January 2024 core group, the Council recognised it did not know which health professionals should be leading on the health actions. However, it failed to properly consider what steps it should take to address this. It then failed to ensure health professionals attended the next RCPC in May 2024. At the May 2024 RCPC the Chair noted the Council had not properly explored concerns raised from June 2023 by health professionals, or pushed for a named point of contact to lead on the health risks to D. The Council recorded it did not know the status of the health report it received September 2023, what it meant in terms of risk to D, and what actions were needed to address any risks. The Council’s failure to properly consider and address this from June 2023 to May 2024, was fault.

Complaint handling

46. The Council’s child safeguarding procedure says a complaint about the outcome of a Child Protection Conference, or the process followed, should be raised with the Child Protection Conference Chair. This will then be passed to the Chair’s manager within Children’s Services, and the Council’s complaints team. The outcome of any such complaint where fault is found could be that the Council reconvenes a conference under a different Chair or decides to bring an RCPC forward.
47. In Ms X’s case, the Council did not respond at all to her complaints made in November and December 2023. This was fault. There were no ongoing court proceedings which prevented the Council from responding to the complaint at that time. The Council said it had concerns that responding in detail may present a risk to D. It is up to the Council to decide what information it should disclose to Ms X. However, it should still have issued a complaint response, and explained any specific points it could not respond to because it considered it should not share the information.

Injustice caused to Ms X

48. As explained at paragraph 31, I have only investigated injustice caused to Ms X.
49. We are not an appeal body for child protection decisions and cannot make decisions about child protection. Our role is to review the process by which councils make decisions and look for evidence of fault causing injustice. We cannot question the professional judgment of social workers where this was not affected by fault.
50. The Council delayed its child protection processes, allowed the Child Protection Plan to drift without substantive action, and failed to properly consider Ms X’s views or respond to her complaint. I cannot say, even on the balance of probabilities, how this fault may have affected the child protection decisions the Council made. I cannot say what the Council would have decided if it had followed its procedures without fault, or if it had properly considered a complaint from Ms X about this. It may be this would not have changed anything for the family. D is now an adult so is no longer under child protection procedures, so we would not ask the Council to carry out further proceedings and make its decisions again.
51. I decided fault by the Council caused Ms X injustice as follows.
• Ms X missed an opportunity to have her concerns about the process considered and responded to, via the correct procedure. If the Council had considered this it is a possibility this could have resulted in a decision to reconvene an RCPC, and decisions being reconsidered. There remains uncertainty for Ms X about how things may have been different, which causes her avoidable distress.
• Ms X spent avoidable time and trouble in bringing the complaint to us because the Council did not respond to it.

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Agreed action

52. Within one month of our final decision the Council will:
1. apologise to Ms X for the faults identified and the impact of those faults. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making its apology;
2. pay Ms X £200 to recognise the avoidable distress, uncertainty, time, and trouble caused; and
3. place a copy of our final decision on its records about Ms X, so there is a record of the faults we identified with how it carried out child protection proceedings.
53. Within three months of our final decision the Council will:
1. review how it handled the child protection proceedings from January 2023 to May 2024 in light of our findings;
2. produce a dated action plan of how it will avoid recurrence of the same faults by making changes to practice and procedure or staff training; and
3. report this review outcome and action plan to its relevant overview and scrutiny committee so it can decide how progress against the plan should be monitored.
54. The Council will provide us with evidence it has complied with the above actions.

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Final decision

55. I have completed my investigation. There was fault by the Council which caused avoidable distress, time, and trouble for Ms X. The Council agreed to our recommendations to remedy this injustice. It will also produce an action plan of how it will avoid recurrence of the same faults and report this action plan to its relevant overview and scrutiny committee for monitoring.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman