Summary: Mr and Mrs X complained that the London Boroughs of Ealing, Hounslow and Southwark failed to manage properly the proposed adoptive placement with them. This led to them not having a child placed with them, as they had expected. We find some fault causing avoidable distress, grief and time and trouble for the complainants. The Councils have agreed the recommended ways to remedy their injustice, and to implement service improvements to prevent a recurrence of faults in this case. We have therefore completed our investigation and are closing the complaint.

The complaints

1. Mr and Mrs X, approved prospective adoptive parents, complained that the London Borough of Ealing (Ealing), the London Borough of Hounslow (Hounslow) and the London Borough of Southwark (Southwark) failed to manage properly the proposed adoptive placement, resulting in a child, Y, not being placed with them as they had been led to expect.
2. Hounslow is the corporate parent for the child, Y. Ealing is the lead agency for the Regionalised Adoption Agency (RAA) called Adopt London West, of which Hounslow and Ealing are members (Hounslow commissioned Ealing to find an adoptive family for Y). Southwark is the lead agency for another neighbouring RAA, Adopt London South, and it assessed and approved Mr and Mrs X as prospective adoptive parents.
3. Specifically, the Councils:
1. delayed in completing paperwork, preventing a move of Y to the complainants, as an early permanence placement;
2. advised the couple to take adoption leave, without providing an adoption certificate, which the complainants then had to cancel, causing disruption to their employments;
3. failed to investigate alleged physical abuse to Y by a foster carer raised by the complainants during the introduction stage;
4. caused the complainants unnecessary expense by getting them to buy toys in advance of the placement and not reimbursing them for these costs;
5. at the last moment, after there had been some meetings between the complainants and Y, it was decided that they were not a suitable match and there were concerns about their emotional vulnerability when this had not been previously mentioned or raised as a concern. (e.i): Information about their past history was also available in the complainants’ prospective adoption assessment report, which staff would have seen before proceeding with the proposed placement;
6. delayed in collecting Y’s clothes after the proposed placement had been stopped; and
7. failed to investigate the complaints properly.
4. Mr and Mrs X say that they suffered the grief of losing a child, to whom they had made a commitment and were forming an attachment to, they have suffered from a loss of personal and professional reputation and their ability to adopt another child has been affected.

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The Ombudsman’s role and powers

5. 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’.
6. 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).
7. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended).
8. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended).
9. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available evidence and decide what was more likely to have happened.
10. 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).
11. 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

12. I have investigated events in 2023 when Mr and Mrs X were first considered as a suitable match for Y to when it was decided not to proceed with the placement.
13. There are some aspects of the complaint, which the Ombudsman cannot investigate, and these include the following:

• data protection issues (the complainants can complain, and have done so, to the Information Commissioner); professional standards about social workers (the complainants can complain, and have done so, to Social Work England); matters relating to the child, Y, after the proposed placement was ended because the complainants do not have parental responsibility; and issues relating to the complainants’ loss of employment.

14. I have not investigated a complaint on behalf of Y during the time of the events of this complaint because Mr and Mrs X did not have parental responsibility.
15. I have also not investigated Mr and Mrs X’s complaints about Southwark’s adoption assessment and review of their approval between 2021 and June 2023 because the complainants could have complained to us earlier and they have also had a detailed investigation from Southwark about these earlier events.

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How I considered this complaint

16. I considered evidence provided by Mr and Mrs X and by Ealing, Hounslow and Southwark in response to my enquiries. Mr and Mrs X have had the opportunity to respond to Ealing’s response to my enquiries, to a paraphrased response from Hounslow and to the response from Southwark. I have spoken on the telephone to Mr and Mrs X and to a senior manager from Ealing, Hounslow and Southwark.
17. We have also discussed current adoption practice with the Department of Education (DfE) and with a national organisation specialising in adoption.
18. I have considered the relevant law, policy and guidance, as stated below.
19. I have divided the complaint into two sections: the adoption process (complaints a-f) and the complaints process (complaint g).
20. I issued a draft decision statement to the Councils and to Mr and Mrs X. I have taken into consideration their additional information before reaching my final decision.

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What I found

The adoption process

21. All councils are required to provide an adoption service which meets their obligations to make appropriate long-term plans for children unable to live with their birth families.  
22. Councils must also recruit and assess prospective adopters, match them appropriately with a child and provide support to the adoptive parents and to the birth family.
23. One of the key principles applying to decisions about adoption must be the child’s welfare throughout the child’s life.
24. Most councils are now part of a Regionalised Adoption Agency (RAAs) where councils merge to provide adoption services.  The purpose behind RAAs is to speed up matching, improve adopter recruitment and support, reduce costs and improve the life chances of some of the most vulnerable children.
25. The Adoption Agency Regulations 2005 and the statutory Adoption Guidance 2013 sets out the process to follow.

Procedures for placing a child in an adoptive placement

26. Once the council has identified a possible suitable match, it must provide the prospective adopters with all known relevant information about the child and should meet the prospective adopters to discuss the proposed placement. It is good practice for the medical adviser to meet the prospective adopters and for councils to explain to the prospective adopter its placement procedures.
27. If a council decides a placement should proceed, it must carry out an assessment of the possible adopter’s support needs and prepare an adoption placement report which is presented to the matching adoption panel. Before a report is sent, a copy of this report should be sent to the prospective adopter, and they should be given ten working days to comment. If the adoption panel recommends the match, the agency decision maker (usually an assistant director) must decide whether to accept the recommendation or not.
28. The prospective adopter should notify their employers of their intention to take adoption leave within seven days of being notified that they have been matched with a child. The agency should enclose a completed matching certificate. Once a decision is made, the agency will need to plan the introductions and the placing of the child with the adoptive parents.
29. Regulation 25(a) of the Care Planning, Placement and Case Review (England) Regulations 2010 allows people who are approved adopters to also be approved as short-term foster carers. These are often referred to as early permanence placements.

Meet before match meetings (or referred to as ‘chemistry’ or ‘bump-in meetings’)

30. All the Councils say that increasingly RAAs are arranging for prospective adopters to meet the child before an adoption panel has approved the match. This practice is not a part of the statutory guidance or legislation above.

Ealing’s adoption procedures

31. Ealing was the family finding agency. When a match is considered a potential placement, the adoptive parents’ social worker and family finding social worker exchange the prospective adopters report and the child permanence report (a detailed report about the child and background).
32. Once satisfied that this may be a suitable match, the child’s social worker, the adoptive parents’ social worker and family finding social worker normally visit the prospective adopters to discuss the placement and the child’s needs. They then prepare the adoption placement report and proposed support plan for the matching adoption panel.
33. A senior manager says that it is not unusual now for there to be a ‘meet before match’ meeting where the prospective adopters meet the child in a neutral, fun way, like at a park, as part of the decision-making process for prospective adopters to decide if they feel a connection to the child. Adopters would already have decided that they want to be matched with a child and meet before match meetings are part of the pre-panel preparation. Although adopters have made a commitment to a child, these meetings give an opportunity to withdraw if they do not feel a connection.
34. The necessary paperwork must be with the panel advisor ten days before a panel hearing, who would then pass this to members of the adoption panel within five days of the hearing. The panel advisor’s role is to quality check the paperwork and raise any concerns about the proposed match.

Hounslow

35. Hounslow was the corporate parent for Y. As required, there was an Independent Reviewing Officer (IRO) responsible for ensuring the Council met Y’s care plan and best interests.
36. A senior manager says that meet before match meetings are used because it is a way to check the chemistry between the child and prospective adopters and they help prevent breakdowns. Hounslow say Mr and Mrs X were viewed only as ‘prospective’ adopters and they were fully aware that they would have to be approved by an adoption panel before Y could be placed with them.

Southwark

37. Southwark is a member of a RAA (Adopt London South). It assessed and approved Mr and Mrs X as prospective adoptive parents in late 2021. The first review of their approval was completed a year later, as required. Southwark completed the necessary enhanced Disclosure and Barring (DBS) checks (criminal and safeguarding checks) and it updated these in mid-2023, as required.

Key facts of this complaint

38. This is a summary of the main events.
39. Mr and Mrs X were approved for one child or a sibling group of two between the ages of 0 to 4 years old. Southwark had several meetings with Mr and Mrs X to discuss adoption issues. It was noted that Mr and Mrs X may find certain diagnosis difficult to manage.

Summer 2023

40. In summer 2023, Southwark sent Mr and Mrs X’s prospective adopter’s report to Ealing and Hounslow for consideration as to whether they would be a suitable match for Y. The Ealing social worker asked the Southwark social worker key questions about Mr and Mrs X’s ability to meet Y’s needs.
41. The Hounslow, Ealing and Southwark social workers visited Mr and Mrs X. The Hounslow social worker made no notes of this visit. Hounslow says that this was because it was a ‘family finding’ visit. Mr and Mrs X asked for the weekend to think about the proposed placement. The next working day they confirmed that they were interested in Y being placed with them.
42. The Ealing social worker completed its Hierarchy of Needs form, setting out its assessment of the possible match. Hounslow agreed to arrange a meeting with the medical adviser for the complainants within two weeks, and Ealing to arrange a provisional matching adoption panel for the middle of the summer.
43. The section on ‘chemistry meetings’ (now called meet before match) on the Hierarchy of Needs form was blank but noted that this should be arranged within two weeks. It was also noted that Y’s foster carer would be unavailable from mid-2023, so Y would have to move to another foster placement. Mr and Mrs X say that the Hounslow and Ealing social workers were therefore keen for them to agree to a placement to prevent a further temporary move for Y.
44. Following this, there was a meeting between the Hounslow social worker, his manager and the Ealing social worker. It was recorded that the professional network “agreed with the decision of progressing with [Mr and Mrs X] as a potential match for [Y] to panel”. Hounslow noted that the placement might be an early permanence placement.
45. Mr and Mrs X say that there were put under pressure to agree to a start date for the proposed placement, and they felt any hesitation would be viewed as a lack of commitment. They say this is why they gave notice to their employers. Mr and Mrs X told the Southwark social worker, however, that they wanted to meet Y before taking the next step and to speak to the medical adviser.
46. The Southwark social worker agreed to discuss with Mr and Mrs X about the need to think about transitional items for Y. These are toys/books which the child would keep at the foster home, but they would take them when moving to the adoptive placement.
47. The Southwark social worker told the Ealing social worker that the couple wanted to meet Y first before progressing further. The social worker told Mr and Mrs X that they could withdraw from the process after the first meeting if they felt there was no connection between them and Y.
48. Following this, there was the first meet before match meeting in a local park with Mr and Mrs X, Y, Y’s foster carer and the Hounslow social worker. Mr and Mrs X say that the Hounslow social worker took photographs of them without their consent or notice, which made them feel uneasy.
49. The Hounslow social worker made no notes of this visit. Ealing recorded that the Hounslow social worker said afterwards he was ‘unsure’ about the placement and needed to speak to the Southwark social worker.
50. Subsequently, there was a meeting between the three Councils’ social workers. The Hounslow social worker said that ‘he was not fully confident with the adopters’. It was agreed that it was not possible to go ahead with an early permanence placement and that Y would need an interim foster placement. The Southwark social worker agreed to discuss with Mr and Mrs X the professionals’ concerns.
51. Mrs X had told her employment that the proposed date for Y to be placed with them was in the summer. Mrs X asked the Southwark social worker for confirmation because her employers insisted on this. The Southwark social worker explained this could only be provided when they had been formally approved by the matching adoption panel. To assist Mrs X, Southwark wrote to Mrs X’s employers explaining the adoption process and stating that it was not possible to provide ‘absolutes’ in terms of timescales and dates.

Medical adviser meeting

52. Mr and Mrs X say that the visit to the medical adviser was crucial before agreeing to a placement. Hounslow says a lack of availability meant there were delays in arranging the appointment, although the Council did not originally contact the medical adviser until after the Southwark social worker had chased this up.
53. In late summer, the Southwark and the Hounslow social workers attended the meeting with the medical adviser with Mr and Mrs X. After this, the couple confirmed that they wanted to proceed with the placement.

Encrypted instant messaging app

54. The Hounslow social worker set up an encrypted instant messaging app so that it would be easier to facilitate communication between the relevant parties, including Mr and Mrs X. These messages are not on Hounslow’s Y’s case file or the Ealing files. Only the Southwark social worker and Mr and Mrs X still have these.

Second meet before match meeting

55. The Ealing social worker consulted the psychologist who completed a detailed summary of Y and how to help Y with transition. The psychologist noted that it seemed the couple had been matched and raised a concern for Y about a second meet before match while also recognising that this may be helpful to the decision making.
56. It was decided that a further meet before match meeting should take place, as some officers had ongoing concerns about the suitability of the placement. A possible adoption panel date was planned for the end of the year.
57. A second meet before match meeting took place. The Southwark and Hounslow social workers attended. Mr and Mrs X say that the Hounslow social worker again took photographs without their consent and told them he had lost the previous photographs.
58. The Southwark social worker emailed both Ealing and Hounslow to say that it had been a positive meeting. She noted that Mr and Mrs X were aware that there would be a further family visit from the social workers, and that a panel hearing would be arranged after this.

Arrangements for a panel hearing

59. The plan was for there to be two further meet before match meetings as it was anticipated that there would be little time after the adoption panel hearing to move Y to Mr and Mrs X before the end of the year. The Ealing records noted that the placement was ‘all moving forward’ and that there was a ‘plan in place’. The meeting also confirmed that the psychologist would work with Y to help transition planning, and to support Mr and Mrs X. It was anticipated that this support would continue post placement.
60. The Southwark social worker told Mr and Mrs X to keep the matching adoption panel date available, now planned for early winter and that the plan was to move Y before the end of the year, confirming this in a text message to Mr and Mrs X.
61. Mr and Mrs X raised a safeguarding concern about alleged physical abuse by the foster carer to Y with the Southwark social worker. Southwark referred this safeguarding issue to the Hounslow social worker. Southwark considered this was a matter for Hounslow and it could not share details with Mr and Mrs X because they did not have parental responsibility for Y.
62. There was a further meet before match meeting at the foster carer’s home. In attendance was the Southwark social worker. There is no separate note of this visit on the Southwark files. There is a management note where it is recorded “there was a [meet before match] at the foster carer’s house which was really positive and [the Southwark social worker] attended to support the couple. The foster carer made the [Southwark social worker] aware of an allegation made against her by [Y] stating she [the foster carer] had bitten [Y] on the knee”.
63. Mr and Mrs X say the Southwark social worker only stayed for thirty minutes of this visit, leaving them with Y and the foster carer (who did not supervise the visit). Mr and Mrs X say that Y referred to them as ‘Mum and Dad’, and showed them around the house, took them up to Y’s bedroom and showed them their toys. They say Y was reluctant for them to leave and asked when they would come back. They say the social worker’s absence meant that they missed witnessing this crucial information and evidence of theirs and Y’s growing attachment.

Preparation for the panel

64. The adoption panel adviser from Ealing received the child permanence report, the prospective adopters’ report, and previous annual review. The panel advisor raised concerns about gaps in the matching information in the prospective adopters’ report.
65. The panel adviser stated Y was older than the age range recommended for Mr and Mrs X and there had been problems with disruptions of adoptive placements where the child was outside the approved age group. The panel adviser also said the annual review was completed twelve months ago, that there needed to be updated medical and DBS checks and evidence of how Mr and Mrs X would support a child with additional needs and through adolescence.
66. Hounslow considered the panel adviser’s advice but confirmed with the other professionals that the plan remained to go to panel. The Southwark social worker updated the prospective adopters’ report, stating that Mr and Mrs X had been reassured by the medical adviser’s information and that they were keen to adopt Y.
67. The Hounslow social worker gave Y’s foster carer a tentative date for Y’s move. Hounslow wanted to ensure Y moved before the end of the year because the foster carer would be away then.
68. Mr and Mrs X discussed with the Southwark social worker the questions, which they had of the psychologist, for a forthcoming meeting. These were about how to manage Y’s transition to ensure they gave a consistent message. Mr and Mrs X met the psychologist via teams, along with the Southwark social worker. Mr and Mrs X were taken back, and found it difficult to engage, because the agenda appeared to be different to what they had expected. Neither the psychologist nor the Southwark social worker made a note of this meeting.
69. The Southwark social worker recorded that she telephoned Mr and Mrs X to discuss the panel adviser’s concerns, explaining that she had been asked to update the prospective adopters’ report on the couples’ learning and address the concerns. The Southwark social worker said it was considered the couple had “done a lot of learning and wouldn’t recommend them for the match if we did not think this was the case but I do find the couple to be unpredictable in meetings and there is a distrust of professionals at times”.
70. Mr and Mrs X confirm the Southwark social worker did telephone them, but she did not discuss the panel’s advisor’s advice, only mentioning the meeting with the psychologist.
71. Mr and Mrs X had concerns about the amended prospective adopters’ report, and how they were portrayed and concerns about the adoption support plan. They considered it was a ‘copy and paste’ job from another support plan. They say that they were told the matching adoption panel was a ‘formality’. They say that they lost trust in Hounslow’s social work practice. They signed the adoption placement report.
72. Mr and Mrs X told their employers they would be taking adoption leave from a specific date because they had been told the introduction plan would start immediately after the panel hearing. Mr and Mrs X have provided evidence from the encrypted instant messaging app from the Southwark social worker confirming that it was anticipated they would be on adoption leave after the panel meeting.
73. The Ealing social worker sent the updated adoption placement report to the panel adviser. The panel adviser stated that there was not time to read all the material and to then send the documents to the adoption panel in time for the planned panel meeting, and therefore, by implication, the date would have to be cancelled.

Decision not to proceed with the placement

74. After this, there was a professionals’ meeting with the Ealing and Hounslow social workers and the psychologist. It was decided that the placement would not proceed. Broadly, the concerns raised were that Mr and Mrs X had been unable to identify the possible challenges for the family, concern about how they had managed the meeting with the psychologist and an uncertainty that they could work effectively with the professional network. Mr and Mrs X say that they were portrayed completely differently in a period of less than a month.
75. The Hounslow senior manager says that the assessment of Mr and Mrs X fluctuated from being positive and then to concerns as the professionals involved had more contact with them. Hounslow say it was a complex situation. All the professionals agreed that the placement should not proceed.
76. Mr and Mrs X say it was very upsetting to be told the placement would not go ahead, and then to have to tell their relatives that the planned family zoom meeting with them that day (to discuss and support the transition of Y to Mr and Mrs X’s home) had to be cancelled.
77. Mr X emailed explaining that they were due to take adoption leave and to cancel this would cause professional damage especially for Mrs X because she planned to take a year off and her employers had found a replacement. Mr X asked for a clear decision.
78. A Southwark social worker spoke to Mr X the next day to explain that the placement would not proceed and Ealing would write to them to explain why.

Events after the decision not to proceed

79. Mr and Mrs X say that they were given some of Y’s clothes in anticipation of the placement. They immediately asked that these be collected and said that Mrs X’s employers wanted evidence that she had taken time off for the previous meetings. They also asked for their expenses for the past months, attending meetings and seeing Y (a four-hour trip).
80. Mr and Mrs X say that Hounslow did not collect these from their home until almost a year later despite their requests to do so.
81. The senior manager from Ealing agreed to write to Mrs X’s employers to confirm that Mrs X had been considered for an adoptive placement and had attended meetings. The senior manager asked for details of their expenses and tried to resolve the issue regarding the collection of Y’s clothes. Mr and Mrs X submitted a claim for £495 including travel costs for the three visits to Y.
82. Ealing did not agree to meet the travel expenses or the cost of books and other items which Mr and Mrs X bought in anticipation of Y’s placement.

The Complaint Process (complaint g)

83. The law sets out a three-stage procedure for councils to follow when looking at complaints about children’s social care services. The accompanying statutory guidance, ‘Getting the Best from Complaints’, explains councils’ responsibilities in more detail. We also published practitioner guidance on the procedures, setting out our expectations.
84. The first stage of the procedure is local resolution. Councils have up to 20 working days to respond.
85. 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.
86. 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. The adjudicating officer should then write to the complainant with a copy of the investigation report, any report from the independent person and the adjudication response.
87. The whole stage two process should be completed within 25 working days but guidance allows an extension for up to 65 working days where required.
88. 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. The council must hold the panel within 30 working days of request, and then issue a final response within 20 working days of the panel hearing.
89. The statutory guidance states that, where a complaint relates to two or more local authorities (councils), the complaint should be considered by the authority looking after the child or, in any other case, by the authority within whose area the child resides. The guidance states that there is a duty to co-operate and good practice suggests that the authority responsible for the complaint should ensure good communication between the authorities.

The Councils’ complaint investigation: Ealing

90. In summer 2024, a manager who had no responsibility for the case issued the Council’s stage one response under its corporate complaints policy. The manager confirmed that messages from the encrypted instant messaging app were no longer accessible, that Ealing’s policy was only to reimburse expenses once formal introductions had begun, and only to issue an adoption certificate once the adoption panel had approved the placement.
91. Ealing recognised Mr and Mrs X’s distress by the decision to withdraw but stated this was based on professional advice in Y’s best interests. Ealing also recognised the complainants’ concern for Y’s welfare but stated the final decision on this was a matter for Hounslow as the corporate parent.
92. Ealing upheld the complaint about the delay in communication and responding to their subject access requests. Mr and Mrs X were dissatisfied.
93. Due to the complexity of the issues, Ealing appointed an independent investigator. The investigating officer found that a senior manager stated that certain ‘issues’ should have been noticed earlier, “a problem that had been compounded by a manager not reading the prospective adopters’ report in sufficient depth”. This failure provided an “opportunity for learning”. (The Ealing senior manager says that this may have contributed but there were multiple factors to cause the placement not to go ahead).
94. The investigating officer found that Ealing did not have a policy about using encrypted instant messaging services and upheld the complaint that these had been deleted and had not been recorded onto the case file.
95. Ealing says that the social worker did not deliberately delete the messages. The fact is the social worker left the group when it was decided not to proceed with the match. But Ealing accepted the messages should have been uploaded on to the files. The investigating officer also noted that Ealing did not have a policy about paying prospective adopters’ expenses unless a match had been approved by the matching adoption panel.
96. Regarding the request to take adoption leave, the investigating officer noted that that there may have been ‘regrettable misunderstandings’ and that this affected Mr and Mrs X’s employment. But the investigating officer did not uphold the complaint because the officer was satisfied by the senior manager’s comment that the social worker would not have made such a mistake. It seems that the investigating officer thought the case had been to the matching adoption panel. But it had not.
97. The investigating officer recommended that the senior manager met Mr and Mrs X (they declined this offer), recognise and apologise for the fact that the service could have acted earlier, make a symbolic payment for their avoidable distress, and to introduce policies on meet before match meetings, expenses policy, and retention of information from encrypted messaging apps. The investigating officer also recommended that Mr and Mrs X be allowed to place their comments on Ealing’s files.
98. Ealing has subsequently introduced the recommended policies. Its telephone app message policy of January 2025 states all parties must agree to details being shared, agree the content and timeframe and the content must be uploaded onto the child’s file.
99. The new meet before match guidance says the key purpose is to benefit the child and would normally be a one off or a series of short observations which would have to be agreed by management. The meeting should be fully recorded on the child’s and prospective adopters’ adoption file by the social worker present. This should include the purpose of the meeting, a summary of the interaction, feedback and analysis.
100. Whether to have a meet before match meeting will be an individual decision for each child. But the Ealing manager says that the RAA considers the same purpose cannot be achieved by virtual observation of the child (which used to be the practice in accordance with the statutory guidance).
101. Ealing has also brought in a policy on transition expenses. This makes clear that there will be no expenses paid for meet before match meetings.

Hounslow’s investigation

102. Hounslow considered that Mr and Mrs X were complaining as former prospective adoptive parents and Y was never placed with them. Therefore, Hounslow considered that this level of relationship did not meet the criteria for the statutory complaints’ procedure. Hounslow says that it sought legal advice.
103. In August 2024, Hounslow replied at stage one of its corporate complaints’ procedure. It referred to the letter from Ealing explaining why the placement had not proceeded. Hounslow did not uphold the complaint that the social worker and team manager had acted ‘negligently’, which led to the decision. Hounslow was confident in the decision making of the professional network. It agreed to place a copy of Mr and Mrs X’s complaint and the response on Y’s case files for when the child was older, which it has done.
104. In early October 2024, Hounslow sent its stage two corporate response. Hounslow accepted that the final decision on whether Y should be placed with Mr and Mrs X rested with it, but it was satisfied it had considered all professionals’ views, and there was no fault in the process. Hounslow also considered the social worker had not instructed Mr and Mrs X to take adoption leave and did not uphold any complaint about the social workers’ conduct. Hounslow advised Mr and Mrs X that they could complain to us.

Southwark’s complaint investigation

105. Southwark commissioned an independent investigation under its corporate complaints’ procedure. Relevant to this investigation, Mr and Mrs X raised concerns that they were told to take adoption leave, that there had been no learning from the complaint, they had not been supported when told the placement would not proceed, and the outcome of the allegations of abuse to Y were withheld from them.
106. The independent investigator only upheld the complaint that any learning from the complaint had not been shared with Mr and Mrs X. The manager apologised that Southwark had not been more robust in seeking to share information about its learning from their complaint and offered to meet the complainants. Mr and Mrs X declined this because they had asked for an agenda, and for the areas to discuss be put in writing beforehand, which they did not receive.
107. In May, Southwark sent its final response, advising Mr and Mrs X that they could refer the complaint to the Ombudsman.

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Findings

Complaint (a): delayed in completing the paperwork preventing a move of Y to the complainants as an early permanence placement

108. Hounslow originally planned for Y to move to Mr and Mrs X as an early permanence placement to avoid Y having a further foster placement. Mr and Mrs X wanted to discuss Y’s medical needs and how this might affect their future development, as well as wanting to meet Y before agreeing to the placement.
109. The plan was that the medical adviser meeting would take place within two weeks, and mention was also made of a proposed panel meeting for the summer. The need for a clear timetable was highlighted.
110. Mr and Mrs X expected the meeting with the medical adviser to take place promptly and they had explained why they could not commit to the placement until they had discussed Y’s medical needs. But there is no evidence that Hounslow took any action to arrange this meeting until after Southwark had chased it up. So, I find Hounslow was at fault for not arranging this meeting as planned, particularly when it had been recognised that a clear timetable was required and Hounslow was looking for an early permanence placement to save Y having unnecessary moves.
111. It is likely that this delay in arranging the meeting with the medical adviser will have contributed to the failure to arrange an early permanence placement. And it contributed to Mr and Mrs X’s loss of trust in Hounslow. But I cannot say that this is the sole reason an early permanence placement did not proceed. There were other considerations at the time in that Hounslow had some concerns about the suitability of Mr and Mrs X as a match for Y.

Complaint (b): advised the couple to take adoption leave, without providing an adoption certificate, which the complainants then had to cancel, causing disruption to their employments

112. During the adoption process, Mr and Mrs X thought they must make sure they were available as requested, otherwise they might be considered uncommitted to Y. But they also needed to give their employers notice of them taking adoption leave.
113. Mr and Mrs X were initially led to believe that mid-summer was a possible date for an early permanence placement. But, a month earlier, it had already been decided that an early permanence placement would not go ahead, and Y required an interim placement.
114. The Southwark social worker explained this to Mr and Mrs X and Southwark agreed to write to Mrs X’s employers. I consider that there was sufficient notice that the mid-summer placement date, for whatever reason, was not viable and Southwark took action to explain this to Mrs X’s employers.
115. Regarding the later proposed date, Hounslow considers that Mr and Mrs X knew that Y would not be placed with them unless they had approval from the adoption panel. Mr and Mrs X say they were told this was a formality. Moreover, as the psychologist highlighted, it looked as if the ‘match’ had been approved, and it is understandable why Mr and Mrs X thought that as well.
116. Mr and Mrs X were asked to keep the adoption panel date free and were told arrangements to place Y with them would start immediately after this. All the Councils had agreed to ensure the necessary paperwork was completed in time for this planned panel hearing. Mr and Mrs X subsequently informed their employers of this plan. Mrs X says this was necessary because her employers needed to find cover because she was going to be on adoption leave for a year.
117. An adoption certificate is only issued once a match has been formally approved. Up to the last moment, all the Councils considered a panel would take place on a specific date.
118. Mr and Mrs X were told to keep the booked panel date free, also that placement introductions would begin very promptly after this, and they were asked to take adoption leave from the date of the panel hearing. Had they not agreed to do this, they consider there would have been questions about their commitment to Y.
119. Accordingly, I find fault by Hounslow and Ealing, as the key decision makers, in that they led Mr and Mrs X to take action to ensure they were available from the date of the panel hearing for the placement to proceed. While I accept it was Southwark who specifically told Mr and Mrs X of these arrangements, I am satisfied that Southwark was relying on the information from the two other Councils, and it was reasonable for it to do so.

Complaint (c): failed to investigate alleged physical abuse to Y by the foster carer raised by the complainants during the introduction period

120. I am satisfied that Southwark responded appropriately to Mr and Mrs X’s safeguarding concerns and took this up with Hounslow. It was for Hounslow to decide what action to take.
121. I recognise why Mr and Mrs X wanted to know what was happening with their concerns. They had met Y and thought that Y was likely to be placed with them. But because they did not have parental responsibility, the Councils were not at liberty to disclose information to them.
122. I do not find fault by the Councils.

Complaint (d): caused the complainants unnecessary expense by getting them to buy toys for Y in advance of the placement and not reimbursing them for these costs

123. Had Mr and Mrs X been formally approved as an appropriate match for Y by an adoption panel, they would have been entitled to their expenses in meeting Y and may have been entitled to a grant to purchase appropriate clothing, toys and bedding for a child placed with them.
124. Ealing has now introduced a policy about transitions expenses which states that expenses for meet before match meetings will not be paid. But, at the time, of the events of this complaint, there was no such policy, and I cannot see any discussion with Mr and Mrs X about any cost to them of undertaking a four-hour round trip to meet Y. There is also no evidence on the Councils’ files that their travel costs were discussed. It also seems that Mr and Mrs X were advised to purchase some transitory toys in anticipation of the placement of Y. Again, I cannot see any discussion with them about whether the Councils would meet these costs.
125. Mr and Mrs X should have been told in writing, at the outset, that their travel costs to see Y would not be met and that only travel costs and a settling in grant would be considered after they had been formally approved as a suitable match by the panel and agency decision maker. I find that Ealing, as the family finding agency, had the prime responsibility to discuss with Mr and Mrs X financial matters and any expenses they might incur prior to formal approval.
126. But I find Hounslow was also at fault because it had responsibility to consider whether there was sufficient guidance for Mr and Mrs X before expecting them to incur certain costs. Mr and Mrs X also say that Hounslow did advise them to purchase some transitional items. Hounslow dispute this. But, on the balance of probabilities, and given the poor record keeping by Hounslow, this is more likely to have happened than not.

Complaint (e): at the last moment, after there had been some meetings between the complainants and Y, it was decided that they were not a suitable match, and that there were concerns about their emotional vulnerability when this had not been previously mentioned or raised as a concern. (e.i): Information about their past history was also available in their adoption assessment report which staff would have seen before proceeding with the proposed match

127. Dealing with the second aspect of this complaint (e.i), information about Mr and Mrs X’s past history was in their adopter’s assessment report which both the Ealing and Hounslow social workers considered and moreover the Ealing social worker sought out some further information from the Southwark social worker, asking relevant questions in particular about Mr and Mrs X’s ability to meet Y’s needs and the uncertainty of these.
128. However, some of the information in the adopters’ assessment report (seen in early summer 2023) was referred to much later in the process and was referred to in Ealing’s letter explaining why the placement would not proceed. Early on, Hounslow had some doubts about the match. On balance, I find that Hounslow let matters drift and there was a lost opportunity for it to carefully consider all the known information at an earlier stage of the process. I therefore find Hounslow at fault.
129. Regarding complaint (e), concerning the meet before match meetings.
130. Mr and Mrs X were invited to meet Y, prior to formal approval, explaining that if they did not feel a ‘chemistry’ with Y, they could withdraw. It is understandably why they wanted to meet Y as offered. But I cannot see Mr and Mrs X were told, or their permission sought, that photographs would be taken and how these would be used.
131. I also do not consider that Mr and Mrs X were forewarned that, in as much as such a meeting was for them to decide whether to proceed, it was also an opportunity for the Councils to decide whether they were suitable for Y.
132. Hounslow had some doubts about the suitability of the match after the first meeting. But there is no clear written evidence from Hounslow what these doubts were and there was no summary of the interaction between Mr and Mrs X and Y at their first meeting, or written analysis.
133. Hounslow and Ealing thought a second meet before match meeting would help in the decision making without evidence of consideration to whether this was in Y’s interests or might be misleading for Mr and Mrs X and whether it was right to assess the ‘doubts’ about the placement in this way. And when the panel adviser raised concerns about the match, again there is little written evidence of why Hounslow and Ealing considered the placement was still viable, and why a third meet before match should take place.
134. The third meet before match meeting took place at Y’s foster home. This was a two-hour visit and, according to Mr and Mrs X, the Southwark social worker stayed for thirty minutes. Given the doubts about this possible placement, and how Y might view such a visit (this being the third introduction), it was essential that this visit was properly observed and supervised. It is also the case that the positive interaction, which Mr and Mrs X say occurred between them and Y, was not considered in the decision making that followed.
135. Accordingly, I find that Hounslow, Ealing and Southwark have been at fault in the way the three meet before match meetings took place and that the record keeping, communication and analysis, by all three was poor. The section on meet before match meetings in Ealing’s records was blank (besides giving a date when this should occur). This illustrates that insufficient thought was given at an early stage to the preparation and purpose of such meetings.
136. Ealing has now recognised that written guidance is required for meet before match meetings and it has issued such guidance. But, at the time of the events of this complaint, there was no such guidance which would have been invaluable to the social workers making these important decisions and making the adoption procedures clear to Mr and Mrs X.
137. Moreover, had Ealing’s current policy on meet before match been in existence at the time, a second meeting would not have taken place without management approval. That would have provided some checks and balance to the merits of proceeding in this way when there were known doubts about the match.
138. I find that Hounslow and Ealing have been at fault for not having a clear policy about how meet before match meetings should be managed and their purpose, especially when such meetings are contrary to the statutory guidance and also may have a particular impact for children in care awaiting placement as well as on prospective adopters.
139. Moreover, Mr and Mrs X’s third meet before match meeting was not observed properly, no separate record of the meeting was made or reference made to the fact the Southwark social worker only remained for thirty minutes of this visit. That was a significant omission by Southwark, and accordingly I find fault.
140. It is also the case that Mr and Mrs X’s meeting with the psychologist proved significant in Southwark’s changed assessment of Mr and Mrs X. Mr and Mrs X feel that this was a covert suitability assessment.
141. There is no written account of this meeting, and the basis for the concerns which arose, and which were then referred on to the decision makers. It clearly was an important meeting and influenced the decision not to proceed. I find that Southwark is at fault for not recording properly the content of this meeting as evidence of the concerns it gave rise to.
142. Additionally, as the corporate parent for Y and decision maker, it was very important for Hounslow to make its own record of all the meetings and visits and to put the messages from the encrypted instant messaging app on the child’s adoption file. Properly recording these important events is also a way to provide the evidence for a written analysis for the decisions made and is helpful to the child when older to understand the care planning. I consider that Hounslow’s record keeping was poor and lacked analysis. That is fault.
143. In addition, I find it was fault for both Hounslow and Ealing to have deleted the messages from the app and not to have placed these on its files. Deleting records means key evidence is lost and inevitably gave rise to suspicions and mistrust by the complainants.
144. I do not consider Southwark failed to update Mr and Mrs X’s DBS checks or complete its annual review on time, as claimed. So, I do not find fault here.
145. The booked panel hearing became unviable on advice from the panel advisor. Had the panel not been cancelled, I cannot say – even on balance - what might have happened.

Complaint (f): delayed in collecting Y’s possessions after the proposed placement was stopped

146. Hounslow should have collected Y’s possessions promptly after the placement did not proceed, as the corporate parent and decision maker. The collection was delayed for nearly a year. Accordingly, I find Hounslow at fault.

Complaint (g): failure to investigate the complaints properly

147. The statutory guidance clarifies that complaints about the placing of children for adoption should be considered under the statutory complaints’ procedure.
148. Hounslow should have, as corporate parent, taken the lead in any investigation and co-ordinated a statutory investigation into all three Councils (in accordance with the statutory guidance). It was cumbersome and time consuming for Mr and Mrs X to have to make three separate complaints and for there to be three separate investigations. And without a joined-up investigation by an independent investigator, this meant that the situation was not assessed in the round and learning from the complaints could not be properly addressed.
149. Accordingly, I find Hounslow has been at fault for not taking the complaint lead.

Injustice

150. I cannot say whether the placement would have proceeded if these faults had not occurred. However, Mr and Mrs X will be left with uncertainty about whether the outcome might have been different. This is an injustice.
151. Mr and Mrs X have also been caused avoidable distress by being advised to make plans for a placement, by the poor handling of the meet before match meetings, by the failure to properly record events and for deleting information, by the delay in collecting Y’s possessions and by the failure to deal with their complaints in a co-ordinated and timely way under the statutory complaints process.

Agreed actions

152. Our primary aim is to put people back in the position in which they would have been if the fault by the council had not occurred. When this is not possible, we may recommend the council makes a symbolic payment. Where that takes the form of a payment, it is often a modest amount whose value is intended to be largely symbolic rather than purely financial. We also support organisational learning and improvements to help others.
153. We do not normally recommend a time and trouble payment just for having to complain to a council or to us. But we recognise that mistakes in a council’s complaint process can cause avoidable time and trouble and we may recommend a small symbolic payment for this.
154. We expect senior officers from councils to make effective, timely and specific apologies for the faults we have identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice.
155. All Councils have accepted the recommended actions, and that is to their credit. They are committed to learning from these relatively new adoption partnerships and complex decision making.
156. Within one month of the final statement, Hounslow will:
1. apologise to Mr and Mrs X for the faults and injustice identified in my findings;
2. make a symbolic payment of £750 to recognize Mr and Mrs X’s injustice which includes their avoidable time and trouble in pursuing their complaints;
3. write to Mr and Mrs X confirming that all photographs taken during the meet before match meetings have been deleted;
4. ensure that Y’s adoption file is updated with all the relevant reports, minutes of meetings and the documentary evidence about the actions taken in 2023. The Council says this has happened, and it is committed to improving its record keeping. But it will need to add the additional records which I have recommended Southwark complete; and
5. place our final statement on Y’s adoption file so that, when older, and Y chooses to access the care records, that will be available.
157. Within one month of our final statement, Ealing will:
1. apologise to Mr and Mrs X for the faults and injustice which I have identified;
2. make a symbolic payment of £750 to recognize Mr and Mrs X’s injustice which includes their avoidable time and trouble in pursuing their complaints; and
3. pay their expenses because they were not told at the outset that these would not be met.
158. Within one month of our final statement, Southwark will:
1. apologise to Mr and Mrs X for the faults and injustice which I have identified;
2. make a symbolic payment of £750 to recognize their injustice to include their time and trouble in pursuing their complaint;
3. Southwark should make a retrospective record of the third meet before match meeting, and of the meeting with the psychologist (and the pre-meeting which Mr and Mrs X say happened);
4. allow Mr and Mrs X to put on their adoption assessment file their account of their last visit to Y, their account of the meeting with the psychologist (and pre-meeting with the social worker) and their subsequent communication with Southwark;
5. place a copy of our final statement on their adoption assessment file; and
6. once all the additional information is placed on the file, Southwark will revise its reference which Mr and Mrs X can use if they wish to approach another adoption agency.
159. It is important for RAAs to be clear about their adoption procedures, particularly now that they are departing from the statutory guidance and regulations. It would also have been helpful if Mr and Mrs X had received written information about the matching process right at the outset.
160. Within three months of the final statement, the RAAs (ALW and ALS) will:
1. work together to prepare a written leaflet (and/or online guidance) specifically for prospective adopters, setting out the procedures for meet before match meetings, their purpose and how they will be introduced to the child, and emphasising that a child will not be placed with them until formal approval by an adoption panel and agency decision maker;
2. it should also be made clear in any guidance that decisions about a second meet before match meeting should be formally approved by management to properly assess and analyse why this might be necessary;
3. the guidance should also explain that there are no payable expenses, and no adoption certificate will be issued until formal approval;
4. if photographs/video are to be taken at the meet before match meetings, prospective adopters should consent in writing and be told what will happen to the photographs. It should be acceptable for prospective adopters not to agree to be photographed without concern that this would be regarded negatively;
5. if prospective adopters decide that, in light of the information above, they would prefer to wait until formal approval, they should be offered the option of virtual observations of the child instead of a meet before match meeting.

In addition:

6. RAAs should have prospective adopters’ formal written consent to the use of encrypted instant messaging apps, and be told that messages (including theirs) will be placed on relevant files;
7. RAAs should arrange meetings with a medical adviser for prospective adopters early in the process because the information provided is often very important for prospective adopters in deciding whether to proceed;
8. RAAs should consider whether prospective adopters would benefit from meeting with the foster carer before they meet the child;
9. RAAs should consider only arranging family zoom meetings/appreciation days, and other transitional arrangements, after formal approval has been given;
10. RAAs should develop a complaints policy that recognises relevant adoption-related matters should be considered under the statutory Children Act complaint procedures, and that there should be a joint, coordinated investigation (when more than one Council/RAAs is involved) led by the corporate parent, or in other cases, where the child resides.
6. The Councils/RAAs should provide us with evidence it has complied with the above actions.

Decision

162. I have found fault causing injustice. The Councils/ RAAs have agreed to remedy the personal injustice and provide service improvements. Therefore, I have completed my investigation and am closing the complaint.

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Investigator's decision on behalf of the Ombudsman