Leicestershire County Council (17 009 175)

Category : Children's care services > Child protection

Decision : Upheld

Decision date : 25 May 2018

The Ombudsman's final decision:

Summary: Ms Y complained the Council failed to keep her granddaughter, B, safe and failed to work in partnership with her. There is evidence of fault causing injustice to Ms Y and the Council has been asked to pay a financial remedy and change its procedures.

The complaint

  1. The complainant, whom I shall call Ms Y, made a number of complaints to the Council about its care of B, who was looked after primarily by her mother (Miss X) under a child protection plan. Ms Y thought Miss X could ‘pick and choose which parts of the child protection plan she adhered to’. The complaints centred on:
      1. Failure to either update the safety plan or failing to ensure the safety plan was followed by Miss X;
      2. Failure to look at evidence the Council asked Ms Y to gather such as pictures of B’s skin problems and how treatment from Ms Y had improved them and of ‘risky males’ (men who were known to the police because of drug and/or sexual offences) going to Miss X’s house;
      3. Failure to investigate an allegation of tampered milk provided to Ms Y by Miss X and bruising found on B;
      4. Failure to consider the event of 12 May 2017 when the police were called to Miss X’s house and Ms Y took B;
      5. The Council allowing Miss X to change GP practice even though the GP practice was a safety factor for B;
      6. (1) Poor record keeping to the extent that discussions held in formal meetings were not recorded. (2) Information shared in 1:1 meetings with the social worker were also not recorded;
      7. Failure to communicate appropriately with Ms Y;
      8. The social worker being biased against Ms Y’s son and failing to set up contact appropriately;
      9. The Council advising Ms Y to look at obtaining a Special Guardianship Order for B but then failing to support it.
  2. The Council did not accept a complaint from Ms Y under its statutory children’s complaints procedure. It considered her complaint through its corporate complaints procedure. Ms Y also asked the Ombudsman to consider the Council’s complaints handling in her case.

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What I have investigated

  1. I have investigated Ms Y’s complaints except for f) (2) to i). I have explained why I have not investigated these parts of the complaint at the end of this Statement.

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The Ombudsman’s role and powers

  1. The law says we cannot normally investigate a complaint when someone could take the matter to court. However, we may decide to investigate if we consider it would be unreasonable to expect the person to go to court. (Local Government Act 1974, section 26(6)(c), as amended)
  2. 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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  3. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
  4. We may investigate complaints made on behalf of someone else if they have given their consent. (Local Government Act 1974, section 26A(1), as amended)
  5. If we are satisfied with a council’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

  1. I considered the information provided by Ms Y and made enquiries of the Council and analysed its response. I refer to ‘Working Together to Safeguard Children’, 2015, which is statutory guidance setting out how children should be kept safe. I also refer to ‘Getting the best from complaints’, 2007, which is statutory guidance as to how complaints about children’s matters should be dealt with. We expect Councils to follow statutory guidance unless they have good reasons not to do so. I sent Ms Y and the Council a copy of my draft decision and took their comments into account before issuing my decision.

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What I found

  1. B was born in November 2016. She was placed on a child protection plan on 24 March 2017 on the grounds of neglect. This was because Miss X had not taken B to her six-week check following her birth and had delayed seeking medical treatment for B after it was advised she did so at a nine-week check by the health visitor. B was not taken to see the doctor until six weeks later by Ms Y. There were professional concerns Miss X could not prioritise B’s needs above her own. There was also a serious domestic violence incident on 9 March 2017.
  2. Ms Y looks after B for two/three nights each week and has done since close to the time B was born. She is a safety factor for B. The social worker told Ms Y that if she did not report concerns to the Council, she would no longer be considered a safety factor.

What should happen

  1. Once a referral is received, in this case from the police because of the domestic violence incident, the Council should decide how to proceed. Councils normally call strategy meetings, involving all of those with an interest in the child and family, which decides what action to take. The Council must consider whether immediate safeguarding action is necessary if the referral brings up significant child protection issues.
  2. If a child is at risk of suffering significant harm we would expect a report to be written by a social worker under Section 47 of the Children Act 1989. If the referral contains enough detail then the Council might start with a Section 47 report. This report would be presented to an Initial Child Protection Case Conference, which would decide if the matter was serious enough for the child or children to be placed on a Child Protection Plan.
  3. ‘Working Together to Safeguard Children’ explains that the purpose of any assessment is always:
      1. ‘to gather important information about a child and family’;
      2. ‘to analyse their needs and/or the nature and level of any risk and harm being suffered by the child’;
      3. ‘to decide whether the child suffering, or likely to suffer, significant harm’ (as in Section 47 of the Children Act); and,
      4. ‘to provide support to address those needs to improve the child’s outcomes to make them safe’.
  4. An assessment is not a one-off piece of work that stays as it is. It should be a ‘dynamic process’. It exists as a way to ‘monitor and record the impact of any services delivered to the child and family and review the help being delivered’. It must be child-focused. ‘Working Together’ says ‘Practitioners should be rigorous in assessing and monitoring children at risk of neglect to ensure they are adequately safeguarded over time. They should act decisively to protect the child by initiating care proceedings where existing interventions are insufficient’. We would expect that if the parent could not show their parenting practice was improving, or they continuing to engage in risky behaviour, the Council would be responsive to this and begin the legal planning process to move to care action.
  5. The way a plan is written is also key. Working Together says that a child protection plan should ‘set clear measurable outcomes for the child and expectations for the parents, with measurable, reviewable actions for them’.
  6. Although documents like safety plans do not have legal status, they are a way of ensuring the parent understands the importance of keeping a child safe. They should be referred to in child protection plans. If they are not being kept to, the Council should decide whether that puts the child at more risk and consider starting care proceedings as a result.
  7. Child protection plans are monitored by Core Groups, which generally meet monthly, and reviewed periodically at review child protection case conferences. The first review is set at three months after the initial case conference and then at six monthly intervals.

What did happen

  1. There is a delay between 9 March (when the domestic violence incident took place) and 20 March (when the safety plan was signed). However, the Council did make an enquiry under Section 47 of the Children Act 1989, and produced a Single Assessment on the family, and Miss X had announced and unannounced visits from social workers. There is no evidence of fault.
  2. The plan, as written, does not ‘set clear measurable outcomes for the child and expectations for the parents, with measurable, reviewable actions for them’ in accordance with statutory guidance. This is fault. The Council should ensure, as a matter of urgency, that social workers understand this principle of plans and are able to work through them logically to check progress or regression.
  3. Although the Council should use evidence to decide if the child continues to be at risk, and the parent is failing to make appropriate changes to the child’s care, there is no evidence this was done. This is fault and the Council should apologise. It should, as a matter of urgency, decide how social workers should use evidence to keep a child’s safety under close review.
  4. Ms Y made specific complaints to the Council about how her granddaughter’s case had been managed.

Complaint a) - Failure to either update the safety plan or to ensure the safety plan was followed by Miss X.

  1. On 20 March 2017, a ‘safety plan’ was signed by Ms Y and Miss X, which was meant to keep B safe. The safety plan says it ‘will be replaced by the plan completed as an outcome of the child protection conference held on 24 March 2017’.
  2. The safety plan says Miss X ‘has not been honest and has (misled) both professionals and family members about what she has (done) to address (B’s) needs and what advice she has been given’. As a result, Ms Y was asked to ‘attend and support’ all medical appointments for B, medical advice had to be followed and medication given and B had to be seen daily by a family member.
  3. The safety plan was not updated at the initial child protection case conference although it is mentioned in the plan. This meeting concluded that Miss X ‘has struggled to adhere to the safety plan in place. When the safety plan was completed and agreed Miss X was happy to comply; however, the reality she did not want to follow this through, as this included Ms Y turning up at any time of the night to monitor and make sure Miss X and the children were ok. This has had a knock-on effect and Ms Y has struggled to see Miss X daily as per the agreement. Professionals were concerned about Miss X not adhering to the safety plan as it raised questions of where would she be and her ability to work in partnership with all agencies involved’.
  4. It was acknowledged the ‘safety plan (would) be revisited. (There was a) need to consider the safety people identified and the protective factors’. This was to be done ‘Immediately and to be discussed and reviewed at first Core Group on 4 April and all future meetings’.
  5. Therefore, the Council was aware the safety plan was not followed even between when it was signed on 20 March and the Initial Child Protection Case Conference on 24 March.
  6. At the Core Group meeting on 4 April, it was acknowledged the ‘Safety plan (had) not been fully kept to’ but no action was taken. There is no evidence the plan was either removed or updated as a result. The agreements in the safety plan were still valid. There is no evidence the Council considered what action to take given it was not being followed. This is fault. This caused Ms Y distress as she felt the Council was not taking her granddaughter’s protection seriously enough. Ms Y had been unable to attend all medical appointments as Miss X or her mother would say they would go instead. There are grounds to suggest that this was not the case and the child would not get taken to medical practitioners appropriately. The Council did not insist that the safety plan should be followed. The Council should make a payment of £200 to Ms Y for the avoidable distress it caused.
  7. The Council should consider whether its procedures are robust enough to enable it to take action if parents are failing to engage with the requirements of safety plans. Although they are not legal documents in themselves, they are a way of satisfying councils that parents are committed to making changes in the way they care for a child. Referencing it in the child protection plan means it is a part of child protection practice.

Complaint b) - Failure to look at evidence the Council asked Ms Y to gather. This includes pictures of B’s skin problems and how treatment from Ms Y had improved them. It also includes photographs of men going to Miss X’s house.

  1. The Council asked Ms Y to take photographs and document B’s skin problems including her nappy rash. I explained above that she was compelled to do this because the Council said it would otherwise not consider her a safety factor for B. However, when she did so the social worker refused to look at the pictures on the grounds they could be considered ‘child pornography’. This is fault. The Council asked Ms Y to document concerns and should have considered the photographs appropriately. This caused Ms Y time and trouble as she had gone to the effort of providing this; she was also shocked she could be accused of producing child pornography, which would obviously cause her distress.
  2. Ms Y felt the Council was deliberately ignoring evidence. Ms Y took the photographs to B’s doctor for her to see instead. She says the Council suggested to the doctor that Ms Y should not have taken the photographs, although if it had asked Ms Y to document the evidence, it is unclear what evidence other than photographs she could have shown. Information, that the Council gained from this, could also have been fed back to the Core Group. The Council should apologise for the social worker not considering the evidence and make a payment to Ms Y of £200 to reflect this time and trouble and pay her a further £100 for the distress it caused by suggesting to Ms Y she might be considered a perpetrator of child sexual abuse.
  3. The Council also failed to consider photographs of men at Miss X’s house, which Ms Y had taken or that had been posted on social media. One of the pictures shows men with drug paraphernalia with Miss X. Another shows Miss X with a man and B. Other Council staff (such as the health visitor) acknowledged men were visiting the property who they did not know. Miss X had been told, at the May Core Group meeting, not to have ‘named people around when she has care of the children’ but considering they did not know who the men were in the house, they could not know whether Miss X was following this instruction or not. The names of these people were not shared and it is not clear how many men had been checked – the Council says there was nothing on file before November 2017 although it has said to me ‘there were various checks done’. This is fault. B could not be kept safe unless it was clear to everyone, not just Miss X, who should not be around B. This also meant it was potentially important for the Council to see photographs in case Miss X was associating with specific people despite what she had said to the Council. It could, and arguably should, have fed this information back to the Core Group. This is fault and the Council should apologise.
  4. There is no evidence the Council considered a letter from a worker at the property where Ms Y’s son was living dated 30 March 2017. This is fault. This supports the allegation that men were going to Miss X’s house, at her request, even when the children were present. As before, the Council should consider how to best manage the evidence it receives, highlights when concerns should be shared and uses the information to inform the child protection plan if appropriate.

Complaint c) - Failure to investigate an allegation of tampered milk provided to Ms Y by Miss X for B and bruising.

  1. On one occasion when B came to stay with Ms Y, she established Miss X had given her the wrong milk. B needed specialist prescription milk and, by that time, had already been on it for around 6 weeks. Miss X had provided milk that set off B’s allergies although in the correct tin. Ms Y says the social worker would not look at the milk and expected the GP to test it. Given B’s allergies started as a result of being given the milk, on the balance of probabilities it could be identified as the wrong milk. At the least, this should have been thoroughly investigated. There is no evidence the social worker took any action to address this even though B was ill as a result. This is fault and the Council should apologise to Ms Y. This should have been discussed at the Core Group meeting for members to be aware of.
  2. At the review Child Protection Case Conference in June 2017, Ms Y said that B had a bruise on her thigh found on 9 June, while she was caring for her. B was immobile at the time and this should have been investigated. Ms Y could have chosen to take B to the GP for a professional opinion. Nevertheless, that the Council did not take action to clarify the reason why this bruise occurred is fault and it should apologise to Ms Y.

Complaint d) - Failure to consider the events of 12 May 2017 when the police were called to Miss X’s house and Ms Y took B.

  1. On 12 May 2017 Ms Y called the police because a baby was crying in Miss X’s house, when Miss X was there, but the crying did not stop. Ms Y says the police identified there was drug taking going on in the garden (which is why Miss X had not heard the baby) and Miss X was with unknown men. I understand Miss X’s aunt was also there at the same time.
  2. As a result, Ms Y says she was advised by the police to take the baby and she kept B for six nights.
  3. The Council has shown me a referral from the police on 12 May but it does not mention this detail. On the balance of probabilities, there may have been more than one referral on that day.
  4. The Core Group was told at the next meeting on 7 June that Ms Y ‘had to call the police due to Miss X having people (around) who were smoking cannabis’. The notes of the meeting say the social worker ‘shared the appropriate contents of the report’. The social worker said ‘The parenting assessment of Miss X is ongoing and there is a plan to address concerns about inappropriate visitors’.
  5. The harm would not be removed, or addressed, by ‘a parenting assessment’. It was fault for the Council not to consider the impact of what had happened on the child protection plan and it should ensure it does this in the future. Ms Y says when she suggested to Miss X she was meeting people who were taking drugs she was called ‘a liar’ even though the police had also communicated this to her. Understandably it caused Ms Y distress as she felt Miss X continued to be unable to prioritise B’s needs above her own even though B was on a child protection plan. Miss X apparently told the police she felt ‘overwhelmed’ with her childcare responsibilities – at the Core Group meeting the health visitor said Miss X ‘s view was ‘she had not had a break’. This was in spite of her mother providing a lot of help and support alongside the nursery, and Ms Y, also being involved. The Council should apologise to Ms Y for this.

Complaint e) - Allowing Miss X to change GP practice even though the GP practice was a safety factor for B.

  1. There are no grounds in law or guidance to prevent someone changing GP practice if they want to do so. I have seen a record of a Professionals Meeting where there was appropriate handover between GP practices. I cannot share this with Ms Y. Ms Y suggests social workers encouraged Miss X to change practices. I have not investigated this as it does not change the fact that Miss X was able to make the change herself. I understand the Core Group did not agree with the choice made and it might be thought social workers could have dissuaded Ms Y from changing practice for that reason. However, there is no evidence of Council fault.

Complaint f) (1) - Poor record keeping to the extent that discussions held in formal meetings were not recorded

  1. What to write in minutes is a matter of professional judgement. We do not expect minutes to be verbatim or to be extremely detailed. Ms Y has given a number of examples where she says significant amounts of discussion took place at meetings, which is not reflected by the minutes (for example, about Miss X meeting risky males, the wrong milk being given and the change of GP practice). On the balance of probabilities, this is sufficient to reach a finding of fault. The Council should ensure the minutes contain details of points of disagreement or concern given the aim is to keep children safe. The Council should ensure minute takers are appropriately trained to enable them to do this.

Complaints handling

  1. The Council did not consider Ms Y’s complaint under the statutory (children’s) complaint procedure. The child protection process does not come under the statutory procedure.
  2. The Council says that grandparents do not have automatic access to complain under the children’s complaints procedure. It was for the Council to decide whether Ms Y met the criteria as “such other person as the local authority consider has sufficient interest in the child or young person’s welfare to warrant her representations being considered by them” in line with the statutory guidance.
  3. The Council says the matter was discussed with the Team Manager with case oversight who felt that Ms Y did not have ‘sufficient interest’. Whilst the Council accepted that Ms Y was being offered contact by Miss X (which did include care), this was not through any legal order or the Council specifying that she had care of the child. There is no evidence of fault.
  4. Ms Y was unhappy that meetings held with her around her complaint were cancelled at short notice or, as she thought, not taken seriously enough. Although I understand how she felt, I have seen evidence the Council tried to deal with her concerns.

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Agreed action

  1. To apologise to Ms Y for the fault in the statement where it has not yet done so within one month of the date of my decision.
  2. To make a payment of £300 for distress and £200 for time and trouble to Ms Y within three months of the date of my decision.
  3. The Council should change its procedures to ensure, as a matter of urgency, that social workers understand and appreciate the need for measurable actions in child protection plans. It should do this within three months of my decision.
  4. The Council should also, within three months of my decision, agree how social workers should use evidence and understand when it is appropriate to raise issues with the Core Group or Child Protection Case Conference and to amend child protection plans.
  5. The Council should ensure its procedures are robust enough to enable the Council to take action if parents are failing to engage with the requirements of safety plans. It should do this within three months of my draft decision.
  6. The Council should ensure minute takers are appropriately trained within four months of my decision.

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Final decision

  1. Fault leading to injustice, remedy agreed.

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Parts of the complaint that I did not investigate

  1. Ms Y has not given me specific dates of 1:1 meetings so I have no evidence whether matters were recorded or not.
  2. Without supporting evidence, I cannot consider this complaint.

Failure to communicate appropriately with Ms Y.

  1. I have found fault with the Council for not considering evidence from Ms Y. This complaint, as made, does not provide any specific information to suggest Ms Y was not communicated with appropriately beyond what I have already investigated. I cannot investigate this complaint without specific evidence.

The social worker being biased against Ms Y’s son and failing to set up contact appropriately.

  1. This is a complaint for Ms Y’s son to make. I do not have signed authority from him to enable me to consider this. I am not investigating this complaint.

The Council advising Ms Y to look at obtaining a Special Guardianship Order for B but then failing to support it.

  1. I cannot see evidence the Council has had an opportunity to consider this complaint. For that reason, I consider it is premature. If Ms Y believes the Council has not provided sufficient support, she can present this to the court.

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Investigator's decision on behalf of the Ombudsman

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