Summary: Mrs X complained about how the Council handled a child protection intervention, and her subsequent complaint. She says the Council’s actions caused significant distress and long term health problems that the remedy offered by the Council did not properly reflect. The Ombudsman has identified some additional fault with the way stage two of the statutory complaints procedure was carried out. To remedy this, the Council has agreed to apologise to Mrs X and make a payment to her.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains about how the Council dealt with a child protection investigation.
2. She also complains about how the Council handled her complaint about this matter.
3. She says the Council’s actions during both the child protection investigation and complaint handling caused a decline in both her physical and mental health. She says the Council’s remedy was inadequate.

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The Ombudsman’s role and powers

4. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we could add to any previous investigation by the Council, or
• it is unlikely further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants.

(Local Government Act 1974, section 24A(6), 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

6. As part of my investigation I have:

• considered the complaint and documents provided by Mrs X;
• made written enquiries of the Council and considered its response;
• considered the Council’s statutory complaints procedure responses;
• considered the relevant law and statutory guidance;
• spoken to Mrs X; and
• sent my draft decision to both parties and invited comments on it that were taken into consideration before making my final decision.

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What I found

Councils’ duties towards children

7. Local authorities have a duty to investigate if there is reasonable cause to suspect that a child in their area is suffering, or is likely to suffer, significant harm. They must decide whether they should take any action to safeguard or promote the child’s welfare. (Children Act 1989, section 47). A child protection enquiry will start with an assessment of the family circumstances and may move on through Strategy Meetings and a Child Protection Conference, which may decide on a Child Protection Plan.

The statutory complaints process

8. The law sets out a three-stage procedure for councils to follow when looking at complaints about children’s services. At stage one of this procedure, the council appoints an Independent Investigator (“the Investigator”) and an Independent Person (who is responsible for overseeing the investigation). If a complainant is unhappy with the outcome of the stage two investigation, they can ask for a stage three panel review (“the Review Panel”).
9. If a council has investigated something under this procedure, the Ombudsman would not normally re-investigate it unless he considers the investigation was flawed. However, he may look at whether a council properly considered the findings and recommendations of the independent investigation.
10. The timescales in working days for the procedure are:

• 10 days at stage one (with a further 10 days for more complex complaints or additional time if an advocate is required);
• 25 days at stage two (with maximum extension to 65 days);
• 20 days for the complainant to request a Review Panel;
• 30 days to meet and hold the Review Panel at stage three;
• 5 days for the Review Panel to issue its findings; and
• 15 days for the council to respond to the findings.

(Department for Education and Skills 2006 Getting the best from complaints: Social Care Complaints and Representations for Children, Young People and Others).

What happened

11. Mrs X lived with her two children. She was separated from their father and was in a new relationship with Mr D.
12. In April 2018, the police were called following a report about an incident of domestic violence between Mrs X and Mr D. This prompted involvement of the Council’s social services department due to child protection concerns.
13. In May 2018, an Independent Child Protection Conference was held. This led to the children being made the subject of Child Protection Plans under the category of neglect.
14. Mrs X was unhappy about the way the Council dealt with this matter and complained in July 2018. Dissatisfied with the Council’s initial response, she escalated her complaint to stage two of the statutory complaints procedure.
15. Her complaint was allocated to the Independent Investigator in September 2018. He agreed a summary of complaint with Mrs X in November 2018. Her complaint consisted of 22 separate complaints. His report informed the Council’s stage two response sent in May 2018.
16. Of the 22 separate matters complained about, 4 were upheld, 5 were partially upheld, 10 were not upheld and 3 where there were no findings.
17. The Council accepted the Investigators report and findings and set out a number of service improvements as well as an apology to Mrs X and a payment of £250.
18. Mrs X was dissatisfied with this outcome and requested a stage three Review Panel that took place in July 2019. Mrs X made both written and verbal submissions to the Review Panel. This led to some changes to the outcome, mainly to “no findings”.
19. In August 2019, a senior officer wrote to Mrs X setting out the outcome from the Review Panel and the Council’s response. In addition to a number of learning points, the Council agreed to pay Mrs X £500 for the distress and anxiety she suffered as a result of its actions during the child protection investigation and a further £150 in recognition of the delay during stage two of the complaints procedure.
20. Mrs X remained dissatisfied with this outcome and so brought her complaint to the Ombudsman in respect of the following matters which I have summarised below.

• Inadequate stage two investigation which led to inaccurate findings, only some of which were corrected at stage three.
• Failure by the Council to support her as a victim of domestic violence, instead focusing only its child protection enquiries and responsibilities.
• Failure to conduct its child protection investigation properly and fairly, demonstrated by poor communication, inadequate recording, failure to follow the child protection plan, delay and misinterpreting the concerns.
• Poor social work practice, particularly by a one social worker (Ms Y), that the Council failed to address during the complaints process. Mrs X has since reported Ms Y to her regulatory professional body.
• Inadequate financial remedy.

Impact on Mrs X and her claimed injustice

21. Mrs X says the Council failed in its duty of care to her as a victim of domestic violence. Both Mrs X and her daughters were not provided with the support they so badly needed at a difficult time in their lives. Instead she says she was threatened with having her children removed from her care. Mrs X says her health has suffered as a direct result of the Council’s incompetence, together with financial losses. She has developed a long-term heath condition.
22. She says the Council’s remedy failed to properly acknowledge this detrimental impact and says she wants “suitable compensation for loss of earnings and impact on my heath”.

Analysis

23. My role is to consider whether there was fault in the Council’s consideration of Mrs X’s complaint. I am aware that Mrs X is unhappy with the outcome of its consideration as it did not uphold every part of her complaint but it is not my role to consider whether its decision was right or wrong but to focus on whether it was reached properly and thoroughly.
24. Mrs X has provided the Ombudsman with detailed written and verbal submissions in support of her argument that the stage two investigation was flawed and the Review Panel failed to properly address this, leading to an unsatisfactory final outcome and inadequate remedy.
25. I have carefully considered the investigations of Mrs X’s complaint, particularly at stages two and three of the process. My findings in relation to the matters Mrs X remains dissatisfied about are set out below.

Inadequacy of stage two investigation

26. Mrs X says the Investigator was obstructive and unprofessional. To illustrate her complaint, she referred me to an email exchange about arranging an initial meeting. Mrs X was given a number of dates but because all three parties involved (Mrs X, the Investigator and the Independent Person) were self employed and had family commitments, this took some time to arrange.
27. Mrs X was understandably frustrated by this delay, but it is clear from the emails that there were good reasons for this and were explained to Mrs X. The delay has already been acknowledged by the Council, so I will not make any further findings about this.
28. During his investigation, the Investigator had sight of the relevant social services case files and interviewed the relevant personnel by way asking them written questions. Mrs X says this was inadequate and he should have spoken to them directly to properly interrogate what they said.
29. There is no requirement within the statutory complaints procedure for verbal interviews to be conducted. However, this omission was considered by the Review Panel. This led to a recommendation that in future, “stage two investigators should interview staff personally unless there are exceptional circumstances”. This recommendation leads me to believe the panel were critical about the investigator’s practices.
30. I am unable to say whether the Investigator’s practice of carrying out written interviews in this case affected the outcome of his investigation. But nor can I say it did not. This is because findings of 10 of 15 heads of complaint considered by the Review Panel were changed at stage three. Some of these changes referred to a lack of relevant information being made available in the stage two investigation.
31. Six of the changes related to “no finding” being reached, often because the records were silent on the particular matter. It is possible such gaps could have been filled in by speaking directly to the personnel involved. This has created some uncertainty as to whether the outcome would have been different had the investigator done things differently
32. This uncertainty is fault. What I must then decide is whether a significant injustice arose as a result of this fault.
33. I have taken the view that most of the inadequacies of the stage two investigation were acknowledged and corrected by the Review Panel. The injustice to Mrs X was therefore partially mitigated by this.
34. Nevertheless, Mrs X still had to suffer the frustration at the outcome of stage two and spend significant time preparing detailed written and oral submissions to the panel to put this right. This is additional injustice for which I consider requires an additional remedy set out below.

Failure by the Council to support her as a victim of domestic violence, instead focusing only on its child protection enquiries and responsibilities

35. Mrs X says the Council should have done more to help her directly as a victim of domestic abuse. Her position is summed up in the written submissions to the stage three panel, “I was the victim of domestic psychological abuse which I eventually fled through my own will and despair…..it was I that needed support, not my children who were loved and cared for.”
36. The complaint process did not directly deal with this issue at any of its three stages. The records show it was not raised by Mrs X until her response to the stage two investigation, except for one matter that I shall deal with later in this decision statement.
37. When Mrs X first complained to the Council in June/July 2018 she was still in a relationship with Mr D.
38. The 22 heads of complaint were agreed between Mrs X and the Investigator in November 2018. Her relationship with Mr D had only just ended. They all related to the s47 investigation and not the Council’s failure to offer her support as a victim.
39. However, the Review Panel was limited to reviewing the matters dealt with at stage two. I do not criticise the review Panel for this.
40. Mrs X has said the Investigator misinterpreted her complaint. But the records show she met with him and she agreed the statement of complaint. I cannot find fault with the Council for limiting the scope of its investigation to matters that were agreed by Mrs X.
41. In my view this was an additional complaint, that arguably fell outside the remit of the children’s statutory complaints procedure. It is reasonable for me to assume that it was only once Mrs X’s relationship with Mr D had come to an end and she had to deal with the fallout from that, that the scope of her compliant about the Council evolved to include this additional element.
42. Because of this I do not find fault here. The focus of the s 47 investigation was on the welfare of the children. This investigation raised concerns about Mrs X’s ability to protect her children. I appreciate this is in direct conflict with Mrs X’s own view. But it is not the role of the Ombudsman to interfere with the professional judgements during such an investigation which inevitably focussed on the welfare of the children.
43. However, Mrs X’s original complaint did include one specific matter about the Council’s failure to recognise her as a victim of domestic abuse.
44. Her first head of complaint was that “Ms Y failed to inform Mrs X of her initial visit”. This was not upheld because the records show that Ms Y did try and contact Mrs X and left a message for her. Instead Ms Y carried out an unannounced visit when Mrs X was at work, but Mr D was home. Ms Y discussed the police referral with him prior to Mrs X’s return and he was present during Ms Y’s discussions with Mrs X.
45. The stage two investigation report did acknowledge the obvious problem with Ms Y’s approach and said, “given that Mrs X was an alleged victim of domestic abuse and that she was injured during the incident it might have been safer to ensure Mrs X was able to openly discuss the violent incident during the initial visit without the alleged perpetrator being there”.
46. But because it of the way the complaint heading was drafted, both the Investigator and Review Panel did not make a specific finding on this matter. I would not expect the complainant to have realised that her complaint would be interpreted so narrowly. Many of the heads of complaint had been subdivided during the stage two investigation and the same should have happened here, because of the importance of the issue.
47. It is clear to me from reading both Mrs X’s response to the stage two investigation and the minutes from the Review Panel hearing that this was a significant element to her complaint.
48. Aside from the comment above from the stage two investigation report, Mrs X’s complaint about inappropriateness of Ms Y’s conduct during that first unannounced visit was disregarded throughout the complaint process. This is fault that caused Mrs X an injustice.

Failure to conduct its child protection investigation properly and fairly, demonstrated by poor communication, inadequate recording, failure to follow the child protection plan, delay and misinterpreting the concerns

49. I have carefully considered the stage two investigation report and Review Panel papers. The Council has accepted there was fault with the following aspects of the s47 procedure:

• Poor communication at certain stages in the process.
• Poor record keeping that limited the Investigator and Review Panel’s ability to reach findings on certain aspects of the complaint.
• Delay in the process and non-adherence to statutory timetables.
• Lack of consistent social work support.

50. The Council’s final response acknowledged the service provided to Mrs X had not been of an acceptable standard and provided a formal apology. The Head of Service also offered to meet with Mrs X to discuss her complaint.
51. The Ombudsman will not reinvestigate these matters because nothing further could be achieved for Mrs X.
52. In respect of the other elements of the complaint that were either not upheld or no findings were reached, I am satisfied decisions were objective and evidence based. Any inadequacies in the stage two investigation were identified and corrected up by the Review Panel and I have acknowledged there was fault here elsewhere in this decision statement. I will not make any further findings of fault here to those already made by the Council for the reasons set out in paragraph nine above.
53. In response to the Ombudsman’s enquiries the Council said a briefing document, highlighting the learning points arising from this case was still to be finalised and circulated. While I welcome this, it is disappointing that this follow work has not yet taken place, partly due to staff turnover. I will address this below.

Poor social work practice, particularly by Ms Y, that the Council failed to address during complaint process. Mrs X has since reported Ms Y to her regulatory professional body.

54. In response to my enquiries the Council said the case did not raise any concerns about the social worker’s professional competence. Therefore, there was no reason to take any disciplinary action in respect of Ms Y.
55. The Ombudsman cannot get involved in decisions about disciplinary action. In any event Mrs X has made a complaint to the Health and Care Professions Council. This is the most appropriate body to consider complaints about social workers’ professional conduct.
56. There is no role for the Ombudsman here.

Inadequate Financial Remedy

57. The Council accepted there were some areas of fault in its handing of this case.
58. The Council offered £500 for distress caused by the faults identified during the complaint investigation and £150 for the delay in the complaint handling.
59. Mrs X says this is inadequate.
60. She says she wants significant compensation, to properly recognise her poor health and loss of earnings. In support of her claim she has provided the Ombudsman with her medical records showing that her mental and physical health deteriorated during the time of both the investigation and subsequent complaint.
61. The Ombudsman’s guidance on remedies says that councils are expected to treat people fairly and with respect and not expose the public to unnecessary distress, harm or risk as a result of their actions. Such injustice cannot generally be remedied by a payment so we usually seek a symbolic amount to acknowledge the fault on the complainant. A remedy payment for distress (which covers undue significant stress, inconvenience and frustration) is often a modest sum between £100 and £300. In cases where the distress is severe or prolonged, up to £1000 may be justified. Occasionally we may recommend more than this.
62. Where there has been significant fault during the complaint process, as was the case here, the Ombudsman’s guidance on remedies suggests making a payment of between £100 and £300 to the complainant.
63. While the medical records I have been shown confirm Mrs X has health problems, I could not reasonably conclude that this was a direct result of any fault by the Council. While Mrs X has a firmly held belief that there was a causal link, in the absence of evidence to support this conclusion, I am unable to make a finding on this aspect of Mrs X’s complaint.
64. The Council’s offer of £500 for distress is in line with the Ombudsman’s guidance and so I will not increase this amount.
65. But I have identified two additional areas of fault with the complaints process that require further remedy set out below. The Council’s remedy of £150 was in acknowledgment of the delay only. As I have identified further fault, this remedy should be increased.

Agreed action

66. To remedy the injustice caused by the additional faults I have identified in this decision statement, the Council has agreed with my recommendation to take the following action within four weeks from the date of my final decision:
1. Apologise in writing to Mrs X for the additional faults identified in this statement.
2. Pay Mrs X an additional £350 (in addition to the £150 already offered) in recognition of the faults I have identified during the stage two investigation.
3. Complete and circulate to all relevant staff a copy of the briefing note informed by the lessons learned from this complaint. A copy should be sent to the Ombudsman.

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Final decision

67. Mrs X has been caused an injustice by the actions of the Council and the Council has agreed a suitable remedy. Therefore, I have completed my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman