Summary: Mrs X complained about the Council’s decision to start child protection action and put her child on a child protection plan. The Council accepted fault in failing to share information about the process with Mrs X, and apologised for the distress caused. We found the Council’s failings did not affect its decision, and its apology is sufficient remedy for the injustice.

The complaint

1. Mrs X complained about the Council’s decision to start child protection action and put her child on a child protection plan. She said the Council failed to properly consider the evidence and failed to tell her the reasons for holding an initial child protection conference.
2. The Council investigated Mrs X’s complaint through the three-stage statutory procedure under the Children Act 1989. It upheld some of Mrs X’s complaints and apologised for the distress this caused. It also agreed to make service improvements.

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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. 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)
5. 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

6. I have investigated whether the Council properly considered the findings and recommendations of stage three complaint panel.
7. To do this, I have reviewed the available case records and the reports from each stage of the complaint procedure. However, I have not re-investigated the findings, or the substantive matters Mrs X complained about. That is because they have already been considered by an investigator and independent person as part of the statutory complaint process.

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How I considered this complaint

8. As part of the investigation, I considered the complaint and the information Mrs X provided.
9. I considered the Council’s response to our written enquiries along with relevant law and guidance.
10. Mrs 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

Child protection

11. 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)
12. When a council has concerns about a child, the law requires it to take action to find out more. It only has to have ‘reasonable cause to suspect’. This is a lower burden of proof than that used by the Police or the Courts who require evidence ‘beyond reasonable doubt’.
13. Councils should act decisively to protect children from abuse and neglect including starting care proceedings where existing interventions are insufficient.
14. 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.
15. 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.
16. 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.
17. The Child Protection Conference is a multi-agency body and is not in itself a body in the Ombudsman's jurisdiction.

Statutory complaint procedure

18. The law sets out a three-stage procedure for councils to follow when looking at complaints about children’s social care services.
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 investigating officer (IO) to look into the complaint and an independent person (IP) who is responsible for overseeing the investigation and ensuring its independence.
21. Following the investigation, a senior manager (the adjudicating officer) at the council should carry out an adjudication. The officer considers the IO report and any report from the IP. They decide what the council’s response to the complaint will be, including what action it will take.
22. 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.
23. The statutory children’s complaints procedure was set up to provide children, young people and those involved in their welfare with access to an independent, thorough and prompt response to their concerns. Because of this, if a council has investigated something under the statutory children’s complaint process, the Ombudsman would not normally re-investigate it.
24. However, we may look at whether there were any flaws in the stage two investigation or stage three review panel that could call the findings into question. We may also consider whether a council properly considered the findings and recommendations of the independent investigation and review panel, and whether it has completed any recommendations without delay.

What happened

25. I have summarised below some key events leading to Mrs X’s complaint. This is not intended to be a detailed account of what took place.
26. Mrs X’s child arrived prematurely and struggled to put on enough weight. Doctors in the National Health Service (NHS) wanted Mrs X’s child to have a gastronomy procedure. Mrs X and her husband (Mr X) were reluctant, and wanted to explore alternatives. There was then a breakdown in relations between Mr and Mrs X and doctors. Mr and Mrs X complained to the NHS and said they intended to withdraw from the doctor’s proposed treatment plan.
27. The Council received a safeguarding referral from the NHS with concerns about Mrs X’s child’s welfare. The referral said medical professionals had not seen the child recently, and Mr and Mrs X withdrew from treatment.
28. The Council held a strategy meeting and decided to advance to an ICPC.
29. A social worker contacted Mr and Mrs X to arrange a meeting. Mrs X declined to take part. The social worker met Mr X and the child at the family home as part of their child and family assessment. The social worker also later spoke to Mrs X twice by telephone and included her comments in their assessment.
30. The social worker’s assessment states Mr and Mrs X understand their child’s basic physical needs, but are not showing the capacity to prioritise their child’s needs despite medical recommendations. The social worker considered Mr and Mrs X were prioritising their own views and assumptions over their child’s health needs, and were not following medical advice. The social worker recorded Mr and Mrs X were exploring other options privately, but had not provided evidence of this. The social worker was concerned the delays in Mr and Mrs X finding alternative care was impacting their child’s weight and development needs.
31. The assessment confirms the child was seen by medical professionals since the Council’s strategy discussion, but the professionals’ safeguarding concerns for the child’s developmental needs remain.
32. The assessment also confirms Mr and Mrs X do not accept the concerns raised and did not want to engage with the CP process. The social worker therefore considered the concerns were substantiated and the child was at continuing risk of harm.
33. Mr and Mrs X attended the ICPC, as well as medical professionals from the NHS. The Council decided to put Mr and Mrs X’s child on a CP plan.
34. The CP plan was for Mr and Mrs X to agree to discuss a gastronomy procedure with the local hospital’s surgical team. They also had to agree to take their child to regular reviews with a hospital doctor, and have them weighed monthly by a community nurse.
35. Mr and Mrs X re-engaged with the hospital about the gastronomy procedure.
36. Following a review, the Council stepped Mr and Mrs X’s child down from the CP plan.
37. Mrs X complained to the Council about errors in the CP investigation, including not sharing safeguarding policies and procedures with them. Mrs X said the NHS lied about them and their child, and it was the NHS who neglected their child, not them.
38. The Council appointed an IO (the investigator) and IP at stage two of the statutory procedure.
39. The stage two investigation report states medical professionals had significant concerns Mr and Mrs X had disengaged from medical monitoring of their child’s health and development. It also points out Mrs X did not want to engage with the CP process.
40. The investigator interviewed the Chair of the ICPC. The Chair said it was their decision to put the child on a CP plan, but in reaching their decision they canvassed opinion from the medical professionals present.
41. The investigator found it was not strictly the case that medical professionals had not seen Mrs X’s child recently. They confirmed Mrs X gave a list of appointments attended.
42. The investigator found no records showing the Council told Mrs X about the process, or that she could give a statement to the ICPC. Although the social worker said they did.
43. The investigator partially upheld Mrs X’s complaint the Chair relied on a majority vote to make their decision. They also upheld Mrs X’s complaint that she was misinformed into thinking the Chair would telephone them before the ICPC.
44. The investigator recommended the Council provide a written leaflet for parents explaining the process, and confirming they can give a written statement.
45. The IP agreed with the investigator’s findings and responses to Mrs X’s complaint. They did not make any extra recommendations.
46. The Council’s adjudication response agreed with the investigator’s findings. The Council apologised for misinforming Mrs X to expect a telephone call from the Chair before the ICPC.
47. The Council also apologised for not making the CP process understandable. It said it would consider sending information leaflets to parents with the ICPC invitation. It also agreed it was reasonable for social workers to tell people they can send a written statement if they wish.
48. Mrs X’s complaint progressed to the stage three Panel (the Panel).
49. The Panel said the investigator’s report did not address whether the social worker gave false or misleading information to the ICPC. The Panel said the information the social worker presented to the ICPC appeared to miss details of the medical appointments Mrs X’s child attended.
50. The Panel was concerned the Council did not tell Mrs X she could complain about the ICPC via the case conference complaint process. It said she lost the opportunity to contest some submissions to the ICPC.
51. The Panel upheld Mrs X complaint there had been a vote during the ICPC. However, it found this was professionally and procedurally the correct thing to do. It considered Mrs X was confused by the process because the Chair failed to meet them before to explain.
52. The Panel said it could not agree or disagree with Mrs X about whether flawed evidence was given to the ICPC. But it said there was no fault in the decision-making, based on the evidence. The Panel also said there were some elements of the complaint it could not reach findings on.
53. The Panel recommended the Council apologise for not directing Mrs X to the case conference complaints procedure, and to consider offering a remedy for any injustice this may have caused.
54. In the Council’s final letter to Mrs X, it considered the recommendations of the Panel. The Council decided an apology for the Chair of the ICPC not meeting Mrs X and not telling them about case conference complaints procedure was enough. It did not consider a financial remedy was proportionate.
55. The Council said it would share the stage two and three reports with senior managers so relevant case conference chairs are reminded about the correct procedures. It did not consider there was value in an internal case review on the points the Panel could not reach findings about. It said the substantive matter had already been considered exhaustively through the three-stage process.

Analysis

56. Neither the investigator nor the Panel found fault in the ICPC decision-making process. The ICPC itself is outside the Ombudsman’s jurisdiction. However, we would not criticise the Chair (who is a social worker and not a medical practitioner) for seeking the views of medical professionals at the meeting in circumstances such as these. The decision on whether the threshold is met for placing the child on a CP plan is one of professional judgement, after considering the relevant evidence.
57. I can appreciate why Mrs X complained the Council should have told her the importance of meeting the social worker to take part in the CP process. However, I do not consider there is enough evidence to say this would have affected or changed the result. Mrs X may not have met the social worker at the outset, but they spoke on the telephone about the safeguarding referral, and Mrs X had the chance to give her views.
58. The Panel highlighted the investigator did not address whether the social worker gave false or misleading information to the ICPC. On the evidence seen, the social worker followed correct procedure in contacting the parents and completing their assessment. The views expressed in the assessment are the social worker’s professional opinion and observations, based on the information from the safeguarding referral, and from their meeting with Mrs X’s husband and the child. I have not seen evidence of factual errors by the social worker.
59. The investigator, and the Panel, highlighted the potential error in the allegation that medical professionals had not seen Mrs X’s child. The Panel was also concerned the ICPC did not have a list of medical appointments. However, I found the social worker consulted Mrs X’s General Practitioner (GP) as part of the child and family assessment, and included details of recent GP appointments in the assessment document shared with the ICPC.
60. I found the concerns of the social worker, the Chair, and medical professionals centred around the parents not following medical advice and disengaging with the treatment plan recommended by doctors. I have not seen evidence to suggest the lack of an appointment list would have affected the result.
61. In conclusion, the Panel did not find fault in the ICPC decision-making process. There were failings in the information shared with Mr and Mrs X, but I do not consider there is strong enough evidence to say this affected or altered the result.
62. I found the Council considered the Panel’s recommendation to offer a further remedy for the impact of its failure to tell Mrs X about the case conference complaints procedure. However, it is satisfied an apology is sufficient remedy.
63. I have considered whether the Ombudsman would recommend a further remedy to recognise Mrs X’s lost opportunity. In doing so I considered the fact the statutory complaint procedure cannot change the ICPC decision, whereas the case conference complaint procedure could. However, as I have discussed above, I do not consider there is enough evidence for me to say the result would have been different but for the faults identified. And there was no fault in the ICPC decision-making process. In these circumstances, the Ombudsman would not ask the Council to accept a late case conference complaint or run the ICPC again.
64. The Council stepped Mrs X’s child down from the CP plan following a review. I am therefore satisfied the Council’s apology is sufficient remedy and there is no significant remaining injustice resulting from the identified fault.
65. I also found the investigator and the Panel’s service improvement recommendations are in line with what the Ombudsman would recommend.

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Final decision

66. The Council accepted fault in failing to share information about the child protection process with Mrs X, and apologised for the distress caused. I am satisfied the Council’s failings did not affect its decision, and its apology is sufficient remedy for the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman