Summary: We have not reinvestigated Mrs Y’s complaint because it has already been subject to a thorough and independent investigation under the statutory children’s complaints procedure. We have also seen evidence to show the agreed recommendations have been implemented by the Council. However, the recommendations do not go far enough in remedying the personal injustice Mrs Y experienced from the fault and the Council has agreed to implement the remedial action in the final section of this statement.

The Ombudsman’s role and powers

4. 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)
5. 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

6. During my investigation I discussed the complaint with Mrs Y and considered the information she provided.
7. I made enquiries of the Council and considered its response.
8. I consulted the relevant law and guidance, which I have referred to in this statement.
9. Mrs Y and the Council had an opportunity to comment on my draft decision. I consider any comments received before making a final decision.
10. 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

Law and guidance relevant to this complaint

Statutory complaints procedure

11. Section 26(3) of the Children Act (1989) says all functions of the Council under Part 3 of the Act may form the subject of a complaint under the statutory complaints procedure. Complaint investigations under the statutory procedure consist of three stages:
• Stage 1: Staff within the service area complained about try to resolve the complaint.
• Stage 2: An Investigating Officer (IO) and an Independent Person (IP) investigate the complaint within 25 days or 65 days, if extended. The IO writes a report which includes details of findings, conclusions and outcomes against each point of complaint (i.e. “upheld” or “not upheld”) and any recommendations to remedy injustice to the complainant.
• Once the IO has finished the report, a senior manager should act as adjudicating officer. They will consider the complaints, the IO’s findings, conclusions, and recommendations, as well as any report from the IP, and the complainant’s desired outcomes. The adjudicating officer should write to the complainant with their decision on each complaint. (Department for Education and Skills 2006 Getting the best from complaints: Social Care Complaints and Representations for Children, Young People and Others).
• Stage 3: A review panel considers the complaint. The panel must consist of three independent people. Following the panel, the members write a report containing a summary of the representations and their recommendations for resolution of the issues. (The Children Act 1989 Representations Procedure (England) Regulations 2006 19(2)).
• 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 set out how the council will respond to the recommendations and what action it will take. If the council deviates from the panel’s recommendations it should explain its reasoning in the response. (Department for Education and Skills 2006 Getting the best from complaints: Social Care Complaints and Representations for Children, Young People and Others).

12. The regulations specify the IO should be independent. They may be an employee of the Council but should have not been involved with the subject matter of the complaint. To ensure impartiality, the process is also overseen by an IP, who is neither an elected member nor an employee.
13. Unless there is evidence of fault in the investigation process, the Ombudsman will not usually re-investigate a complaint which has been through the full procedure. This is because a properly conducted investigation is independent and robust.

Brief background of key events relating to the complaint

14. Mrs Y has three young children, who I will call B, C and D. B sadly died at eight weeks old. C became subject to a CIN Plan on 30 April 2021 which remains open. D became a Looked After Child (LAC) under an Interim Care Order on 16 June 2015 and subsequently a Final Care Order on 25 April 2016. D lived with their maternal grandparents until May 2017 when they returned to live with Mrs Y and her husband, who I will call Mr Y. D remains subject to a care order.
15. The Council has considered discharging D’s care order, but those plans were recently placed on hold following a period of instability at home.
16. Throughout the Council’s involvement with C and D, Mrs Y and her family have been allocated to several different social workers. Mrs Y made a complaint to the Council about some of her experiences.

Stage Two findings

17. The Council allocated an IO on 8 September 2022 to independently investigate Mrs Y’s complaint at the second stage of the statutory complaints process. The IO completed their investigation and issued a report on 8 February 2023. The IP also issued their report 6 February 2023. The IP agreed with the IO’s findings and raised no concerns about the investigation process.
18. During their investigation into Mrs Y’s complaint, the IO interviewed 12 officers and consulted a further five professionals. The IO reviewed the case files for C and D in detail. The IO upheld the following complaints:
• Mrs Y often found it difficult to contact Social Worker 2 [SW2] (Complaint 1c)
• Social Worker 3 [SW3] did not return Mrs Y’s phone calls regarding problems she reported about D’s school (Complaint 1e)
• SW3 did not provide adequate support in relation to the problems D was experiencing at school and did not attend a meeting about this (Complaint 1f)
• Mr Y received confusing and conflicting information when a Council officer he spoke to did not give their correct name. (Complaint 3)
• Mrs Y did not receive adequate notice for meetings and was often contacted only one or two days beforehand (Complaint 4)
• The Council did not use creative methods to meet the language needs of service users to ensure they can access relevant courses (Complaint 6c)
• A scheduled meeting did not go ahead due to SW2 being unexpectedly absent from work and Mrs Y was not informed beforehand. (Complaint 14e)
• Care Planning and CIN reviews were not always held as they should have been. (Complaint 15b)
• Social workers did not always contact Mrs Y within specified timeframes due to their caseloads. (Complaint 15c)
19. The IO partially upheld the following complaints:
• Mrs Y experienced problems when trying to contact SW1. Other professionals also passed comment on their difficulty when trying to reach SW1 (Complaint 1a)
• Social Worker 1 [SW1] did not complete a 28-day review with D and when Mrs Y raised this, a manager said they were very busy (Complaint 5)
• Mrs Y was not informed that the ‘Early Help’ worker would no longer be involved in C and D’s cases. Mrs Y only found out when she chased up the progress of referrals made (Complaint 7)
• SW2 broke professional boundaries when they made physical contact with Mr Y to re-construct a scenario when he lifted D up (Complaint 14d)
20. The IO did not uphold these complaints:
• SW2 did not respond to Mrs Y’s messages which were left with admin staff about an incident involving D in December 2021 (Complaint 1b)
• SW3 is difficult to contact and did not always return phone calls (Complaint 1d).
• Mr Y called the contact centre and spoke to a business support officer who he said was rude and inappropriate (Complaint 2b)
• The family support worker failed to refer Mrs Y onto a course (Complaint 6a)
• The Council offered Mrs Y a place on a course which she could not attend due to childcare commitments (Complaint 6b)
• The Council did not explain the necessity and content of the courses with Mr Y who needed an interpreter (Complaint 6d)
• The Council ignored Mrs Y’s request for another ‘Early Help’ worker. (Complaint 8)
• SW2 was not supportive when Mr Y left the family home for a period in December 2021 (Complaint 9)
• SW2 told Mrs Y to break police bail conditions otherwise it would be a long time until Mr Y could see the children again (Complaint 10)
• The Council failed to attend the inquest into the death of B, despite having interest in the outcome (Complaint 12)
• The Council told Mrs Y they would remove C and D from her care (Complaint 13)
• SW1 did not act appropriately and within their role when Mr Y left the family home (Complaint 14a)
• The Council failed to provide Mr Y with advice when he left the family home. (Complaint 14bi)
• Visits to C and D did not take place at the agreed frequency of four to six weeks (Complaint 15a)
21. The IO made an inconclusive finding for the following four complaints:
• When Mrs Y visited the Council offices on 18 October the duty social worker she spoke to was rude and unhelpful (Complaint 2a)
• The Council should have done more to ensure C and D received their Christmas gifts from Mr Y (Complaint 11)
• SW2 made inappropriate remarks towards Mr Y and referred to him as a ‘cuddly bear’ (Complaint 14bii)
• SW2 had inappropriate discussions with Mrs Y about divorce proceedings (Complaint 14c)
22. The IO made the following recommendations:
• The Council to apologise to Mrs Y for all partially and fully upheld complaints. (Recommendation 1)
• The Council to consider putting a process in place to ensure meetings are cancelled and attendees notified in cases where a SW is unexpectedly absent. (Recommendation 2)
• The Council to ensure the quality of its case note recording continues to improve. All SWs to be reminded of the need to make case notes about all contact with parents and carers and to ensure that minutes of all formal meetings are recorded in the case file (Recommendation 3)
• The Council to remind all SWs to ensure that Care Planning Meetings and CIN reviews are held in a timely manner (Recommendation 4)
• The Council to consider the size of SW’s workloads and continue to work towards reducing these wherever possible (Recommendation 5)
• The Council to pass on Mrs Y’s request to the SW and team manager to receive support with D and Mr Y’s relationship especially around cultural expectations (Recommendation 6)
• The Council to ensure the business support team have information about the complaints team to appropriately signpost callers wishing to make a complaint (Recommendation 7)
23. Following completion of the stage two report, the Council wrote to Mrs Y on 22 February 2023 to confirm its adjudication of the complaint. The Adjudicating Officer (AO) agreed with all complaint findings and offered their sincere apologies for all complaints either partially or fully upheld.

Stage Three findings

24. Mrs Y asked the Council to escalate her complaint to the third and final stage of the statutory process. After the stage three panel reviewed the findings, it made some amendments to the complaint outcomes:
• Complaint 1b changed from not upheld to upheld
• Complaint 1c changed from upheld to partially upheld
• Complaint 2b changed from not upheld to inconclusive
• Complaint 5a) changed from partially upheld to upheld
• Complaint 7 changed from partially upheld to upheld
• Complaint 12 changed from not upheld to upheld
• Complaint 14c changed from partially upheld to inconclusive
• Complaint 15 changed to partially upheld
25. The letter sent to Mrs Y on 30 August 2023 contained a further apology made on behalf of the Council for all areas of complaint which were either partially or fully upheld. The letter also confirmed the agreed recommendations:
• The Council to produce a customer care policy stipulating the time required for SWs to respond to calls (Recommendation 8)
• Where relevant CCTV exists, the Council should ensure the footage is reviewed at Stage 1 of the complaints process and within 31 days of the alleged incident (Recommendation 9)
• The Council to give practice guidance to SWs about signposting families to bereavement support where this is an identified need (Recommendation 10)
• The Council to continue with its development programme and to ensure staff are aware of their obligation to provide timely and accurate case notes when working with families (Recommendation 11)
• Any outstanding actions from the Stage 2 action plan to be completed as soon as possible and within one month (Recommendation 12)

The Ombudsman’s analysis

26. As paragraph 13 of this statement sets out, it is not our role to reinvestigate matters which have already been subject to a properly conducted and independent investigation. To do so would not be a good use of public resources.
27. However, we may look at whether there were any flaws in the stage two investigation or stage three review panel which call the findings into question. We may also consider whether the Council properly considered the findings and recommendations of the independent investigation and review panel, and whether it has completed any recommendations without delay. When doing so, we consider the following key factors.
1. Was the investigation properly conducted and are the conclusions evidence based. If not, would the Ombudsman reach a different view based on the information available to us?
2. Did the Council offer a proportionate remedy for the injustice caused by fault? If not, would the Ombudsman recommend any further remedial action?
3. Has the Council fully implemented any agreed remedy? If not, has the delay caused any further injustice to the complainant?
28. In my view, the stage two investigation was properly conducted and produced evidence-based findings. It is unlikely the Ombudsman would reach a different view based on the available evidence and for this reason I have not reinvestigated Mrs Y’s complaints.
29. I am also satisfied the Council produced proportionate and wide-ranging service improvements with a view to preventing the same fault from re-occurring. In my view there are no further service improvements for the Ombudsman to recommend. I have also seen evidence to show the Council has implemented all agreed actions.
30. However, it is my view that Mrs Y experienced personal injustice which has not yet been remedied. Many of the upheld complaints relate to poor customer service, including failures to return calls, failure to attend meetings due to absence and not keeping to agreed timescales for important meetings and reviews. In my view, the fault has caused avoidable distress, frustration and time and trouble which the Council will acknowledge with a symbolic payment in addition to the written apology it has already provided.

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Agreed action

31. Within four weeks of my final decision, the Council has agreed to:
• Pay £500 to Mrs Y. This is a symbolic payment in recognition of the avoidable distress she has experienced from the fault identified by the complaints investigation.
32. The Council should provide us with evidence it has complied with the above actions.

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Final decision

33. I have completed my investigation. The actions listed in the section above will provide an appropriate remedy for any outstanding personal injustice caused by fault.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman