Summary: The Ombudsmen does not consider it would likely find fault with how a child protection conference decided to support Mr X’s children. Also, the Ombudsmen could not achieve anything more by investigating Mr X’s complaints about York Teaching Hospital NHS Foundation Trust’s communication with him and North Yorkshire County Council.

The complaint

1. Mr X complains about North Yorkshire County Council (the Council) and York Teaching Hospital NHS Foundation Trust (the Trust). Specifically, he complains about:
• The Trust’s miscommunication between 2 and 16 July 2019 when investigating his son’s fracture, which was frustrating.
• The Trust and Council’s poor communication when a social worker attended his home on 17 July, when he was at the Trust with his son.
• The Child Protection Conference (CPC) wrongly decided to place his children on child protection plans. The CPC did not consider one doctor’s opinion that Mr X’s explanation for his son’s fall was consistent with the spinal fracture. This caused Mr X and his family significant distress. Also, the child protection procedures caused them uncertainty about moving to America.
2. Mr X would like a better apology. He would also like the organisations to pay his extended family for hotel expenses when they had to supervise him and his wife around his children.

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The Ombudsmen’s role and powers

3. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue an investigation if they believe it is:
• unlikely they would find fault; and/or
• it is unlikely they could add to any previous investigation by the bodies (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

4. I have considered information Mr X has provided in writing and by telephone. Mr X had an opportunity to comment on my draft decision.

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What I found

Background

5. On 2 July 2019, Mr X was changing his infant son on the sofa. When his other son entered the room, Mr X said he moved to grab a dangerous substance from his hands. As he turned round, his son was falling from the sofa, and believed he grabbed him before he hit the floor. Mr X’s son seemed in pain that evening so took him to the Trust, where he had an X-ray and stayed overnight. The next day the Trust sought a second X‑ray for 7-10 days. Mr X could return home, but if the X-rays confirmed a fracture, the Trust would need refer Mr X and his son to the Council’s safeguarding team. Mr X later received an X-ray appointment for 12 July.
6. On 6 July, the Trust asked to see Mr X and his son for an X-ray on 9 July. A consultant said C had not fractured his leg and would not need to come to the 12 July X-ray appointment. A paediatrician was happy with Mr X’s son, so they could return home.
7. The Trust told Mr X the X-ray on 9 July happened too soon. Therefore, the Trust carried out a third X-ray on 16 July. That X-ray confirmed Mr X’s son had fractured his leg. Therefore, the Trust’s policy for fractures in non-mobile children meant Mr X’s son needed a full skeletal X-ray. The Trust also referred Mr X to the Council’s safeguarding team and to the police.
8. The next day, the Trust carried out the full skeleton X-rays. Also, a social worker attended the family home by mistake. The social worker later attended the Trust and met with a paediatrician. They decided Mr X and his wife would need to be supervised with their son while the Council carried out section 47 enquiries.
9. The Child Protection Conference (CPC) on 6 August decided to place Mr X’s children under child protection procedures. A few weeks later, the Review Child Protection Conference (RCPC) later confirmed it had no further concerns and ended the child protection procedures.
10. In September 2019, the Trust and the Council jointly responded to Mr X’s complaint. They apologised for the miscommunication that led a social worker to attend Mr X’s home when Mr X was in hospital with his son. The Trust also apologised for the confusion caused when it changed his son’s clinical plan between 12 and 16 July.
11. In March 2020, the Council provided its Stage 1 response. It apologised again that a social worker attended Mr X’s home, rather than visit him and his son in hospital on 17 July. The social worker understood his son was an outpatient and would be at home. Also, the Council did not find any fault in its decision to place Mr X’s sons on child protection plans. That decision as unanimous.
12. In July 2020, the Council provided its Stage 2 response, including the Independent Officer’s report. It said it was satisfied the Council acted in line with the local safeguarding guidelines. The CPC considered the views of all medical staff before its decision.

Analysis

Miscommunication in July 2019

13. I do not consider an investigation into Mr X’s two complaints about miscommunication would add anything more to the Council and the Trust’s investigation.
14. The Council and the Trust have apologised for the poor communication in July 2019. I am satisfied those apologies remedy the injustice Mr X suffered. I would not likely recommend anything further in an investigation, including hotel expenses. I do not agree the miscommunication caused that injustice. The supervision order would have been in place regardless of the organisation’s poor communication. Therefore, I will not investigate Mr X’s complaints about miscommunication.

The child protection conference decision

15. Anyone who is concerned that a child is suffering or at risk of harm should inform the Council. Health bodies should be alert to the possibility that children may be at risk of harm and refer their concerns to the local authority for assessment.
16. Councils have a duty to conduct an investigation if they have reasonable cause to suspect that a child who lives in their area is suffering, or is likely to suffer, significant harm. (Children Act 1989, section 47(1))
17. Under section 47 of the Children Act 1989, 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. This may involve an initial assessment and a ‘core’ assessment (a more in-depth assessment). Assessments are intended, for example, to analyse a child’s needs and the risk of harm to the child. Councils may also convene a CPC. The CPC will decide whether any action is necessary to protect the child from harm.
18. I am unlikely to find fault with how the CPC considered the medical opinions of doctors before making its decision. I will explain why.
19. In their report, the Independent Officer recognised the CPC considered the different views. The paediatrician who attend the CPC (Dr A) agreed Mr X’s son’s fracture could have been accidental. However, Dr A “felt there were bits missing from the story” to explain how the fracture happened. The CPC record also said: “reports say [Dr B] stated it was possible for a fracture to be caused in this way [in the way described by [Mr X]]”. The Independent Officer was satisfied the CPC considered Dr A and B’s views before deciding to impose child protection procedures.
20. I do not doubt the CPC considered both doctor’s views. Clearly, Drs A and B had different views, which is common at CPCs. Because Dr B had a seemingly different opinion to Dr A, it did not mean Dr A’s concerns were invalid. I consider Dr A recognised it was a difficult case but had concerns about how the facture happened. Based on this, I am unlikely to find fault with how the CPC decided to support Mr X’s son.
21. I understand how Mr X would have felt frustrated. Dr B’s comments suggested he agreed Mr X’s son’s fracture could have been caused in the way Mr X suggested. However, after the CPC, the NHS Head of Safeguarding clarified Dr B’s view on the fracture. During the RCPC, she said: “[Dr B’s] opinion in [the report for the CPC] may have been misquoted...[Dr B] was giving an opinion on whether there was a fracture, not on whether the explanation could have been the cause of this”. This showed Dr B only intended to say if there was a fracture, not to comment on how it was caused. If the Trust had clarified Dr B’s comments before the CPC, the outcome would most likely not have been different.

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Final decision

22. I consider I am unlikely to find fault with how the CPC decided to support Mr X’s son. Also, I have not investigated Mr X’s complaints about miscommunication because I would not likely recommend anything further in an investigation.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman