Summary: there was fault in the Council’s handling of some matters during the period of its investigation of concerns about a non-accidental injury to Ms G’s daughter. Its handling of her complaint was also poor. The Council will apologise and make a payment to Ms G to recognise the injustice to her and provide an update on changes to social work practice to ensure the identified fault is not repeated in future.

The complaint

1. The complainant, whom I shall refer to as Ms G, says there was fault in the actions of the Council’s children’s services team in relation to its involvement following her daughter, X, making an allegation that Ms G had scratched her in May 2018. Specifically, Ms G complains that:

1. the Council did not have grounds to remove X from her care following the allegation;
2. she did not consent to her daughter being placed with a relative under section 20 of the Children Act 1989 for five days;
3. the Council failed to ensure X was properly cared for whilst she was accommodated as she was not given prescribed medication, not taken to her usual after school activities and not taken to school on time;
4. the Council wrongly decided to make X a Child in Need under section 17 of the Children Act 1989 at a child protection case conference; and
5. the Council failed to consider her complaints about these matters in a timely manner under the correct complaints procedure since May 2018.

2. Ms G was assisted by her local Member of Parliament (MP) in making her complaint to this office.

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The Ombudsman’s role and powers

3. 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)
4. 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

5. I considered the written information provided by Ms G with her complaint. I made written enquiries of the Council and considered all the information before reaching a final decision on the complaint.
6. I gave the Council and Ms G the opportunity to comment on my draft decision and took account of their responses before reaching a final decision on the complaint.
7. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Office for Standards in Education, Children’s Services and Skills (Ofsted), we will share this decision with Ofsted.

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What I found

What should have happened

8. Where a child is considered to be suffering or likely to suffer significant harm a council must make enquiries under section 47 of the Children Act 1989, to establish the child’s situation and to determine whether protective action is required.
9. Whenever there is reasonable cause to suspect that a child is suffering or is likely to suffer significant harm there should be a strategy discussion involving the council’s children’s social care team, the police, health and other bodies such as the referring agency. The purpose of the discussion is to determine the child’s welfare and plan any action needed.
10. If the information gathered substantiates concerns and the child may remain at risk of significant harm the social worker will arrange a child protection conference.
11. A child protection case conference is a formal multi-disciplinary meeting which considers whether concerns about a child meet the threshold of him/her continuing to be at risk of significant harm. The child’s social worker writes a report for the conference and should meet and discuss this with the child’s parent(s) before the conference. Parents are usually invited to the case conference and are permitted to take someone else with them for support including a solicitor if they wish. Where a child is still considered to be at risk the conference will decide the child requires a child protection plan to ensure their safety and wellbeing.
12. A child is considered in need under section 17 of the Children Act 1989 if it is considered they are unlikely to achieve or maintain a reasonable level of health or development, or whose health and development is likely to be significantly or further impaired, without the provision of services or if they are a child who is disabled.
13. Section 20 of the Children Act 1989 provides councils with the power to provide accommodation for children without a court order when they do not have somewhere suitable to live. The child’s parents must agree to the child being accommodated.
14. The law sets out a three stage procedure for councils to follow when looking at complaints about children’s social care services. At stage 2 of this procedure, the Council appoints an Independent Investigator and an Independent Person (who is responsible for overseeing the investigation). If a complainant is unhappy with the outcome of the stage 2 investigation, they can ask for a stage 3 review. Under the three stage statutory complaints procedure the Council should complete its consideration of the complaint at stage 1 in 10 working days, the second stage in 25 working days (extended to a maximum of 65 working days with the complainant’s agreement) and hold an independent review panel within 30 days of the complainant’s request for this.

What happened

15. In May 2018 a professional working with X made a referral to the Council’s children’s services team to say that she was concerned about X as she had an injury to her face which she said had been caused by her mother hitting her when she had been very angry with her about X’s earlier behaviour.
16. A social worker visited X at school on the same day and spoke to Ms G. On the same day the Council arranged a medical examination of X which concluded that injuries to X’s face and neck were not accidental and that concerns about physical and emotional abuse of X were therefore substantiated. The record of the section 47 investigation on the same day note that X was safe as she was staying with a relative and also that Ms G said she did not want X back in her care. A later assessment and report for an initial child protection case conference state that on the day X made the allegation Ms G said she did not want X back, and that she wanted the social worker to collect X’s belongings and put her in a home as she couldn’t cope anymore and she’d had enough of X. The investigation by children’s services and the police was noted to be ongoing. X was noted as saying she did not want to return to Ms X’s care.
17. The Council agreed with Ms G that X should go and stay with a relative on the day of the allegation.
18. The Council convened a strategy meeting the following day. The outcome of this meeting was to undertake an investigation under section 47 of the Children Act 1989.
19. X returned to her mother’s care five days after the agreement was reached for her to stay with Ms G’s relative. The return was agreed because, after seeking legal advice, the Council drew up a written agreement which Ms G signed agreeing she was not use “physical chastisement” towards X and that an initial child protection case conference would be arranged to consider the risk to X.
20. The case conference took place in early June and considered the outcome of the assessment completed by the social worker in early June. The assessment noted the background including previous concerns reported to children’s social care and input from staff at X’s school and a therapist who worked with X. I note that in the case conference meeting Ms G complained that the Council did not complete any background checks on the relative with whom X went to live and did not ask this relative to contribute to the conference. She also said that she believed X had remained with her relative for too long and that the length of stay disrupted her usual social activities and that X’s prescribed medication was not provided to X during her stay there. The notes of the conference indicate that the chair told Ms G that she could pursue a complaint about these issues separately if she wanted to.
21. Having considered the evidence the unanimous decision of those attending the conference was that a child protection plan was not necessary and that support should be provided to X and Ms G under section 17 as X met the criteria of being a child in need.
22. Support was provided under a child in need plan until July when children’s services ended its involvement.
23. Ms G complained to the Council in May 2018 and followed this up in June, August and October when she had not received a response. It seems the team manager responded in November 2018 but Ms G was not satisfied with her response and she asked for it to be considered again but received no further contact until June 2019. After complaining to this office, we referred the complaint back to the Council and a further response was sent to Ms G in October 2019. The response provided in October 2019 by a senior officer in the social care team addressed the following complaints (the October 2019 outcome of these complaints is provided in the brackets following each complaint):
• The Council failed to complete proper checks on her relative before allowing X to stay with her and did not check the suitability of her accommodation. She said she considered the placement to have been a placement under section 20 if the Children Act 1989. In her complaint she said that she agreed X could stay with her relative overnight which children’s services looked into the injury to X (this complaint was not upheld as the Council said Ms G suggested her relative look after X and so the Council considered Ms G considered her suitable and the arrangement was not made under section 20);
• That she had not agreed to X staying with her relative for more than one night, social workers failed to update her or respond to her calls in the days after and the only reason X was returned to her care after five days was that Ms G insisted a decision was reached. She said the situation had caused X significant distress (this complaint was upheld);
• The social worker delayed passing on X’s essential prescribed medication to the relative until one night after she went to stay with her (this complaint was upheld and the seriousness for X recognised though the Council considered it the result of error by the social worker who had picked up the medication but simply forgot to pass it on);
• Social workers made inadequate attempts to contact Ms G when the allegations were first made and investigated in May 2018 (this complaint was upheld as the officer considering the complaint considered they should have attempted other ways to get in touch with Ms G after failing to contact her successfully by phone, for example, by email or visiting her);
• The social worker only spoke to Ms G about X returning home following the intervention of Ms G’s local MP and then required her to sign a written agreement which Ms G felt forced to agree to before X was allowed to return home (this complaint was upheld insofar as the officer stated that a written agreement was justified given the confirmation on non-accidental injury by the medical but that social workers should have made more strenuous efforts to contact Ms G on the day of the medical to agree this and this would have meant X could have returned home that day and not remained with the relative over the weekend); and
• The council delayed in dealing with her complaints (the Council accepted the handling of the complaint was unacceptably delayed and upheld this part of the complaint).
24. The officer said that she would be meeting with the relevant social worker and social work team manager to discuss what needed to be learnt from the matters raised and faults identified in Ms G’s complaint.

Was the Council at fault and did this cause injustice?

25. The Council did not remove X from Ms G’s care following the allegation and medical examination in May 2018. As a result of the confirmation of non-accidental injury at the medical examination the Council agreed with Ms F that X could live with a relative until the Council’s investigated the injury. Had Ms G not agreed the Council would have had to consider whether there were grounds to seek a court order in order to place X elsewhere while they completed their investigation or to obtain Ms G’s consent for X to be accommodated under section 20. However, this was not necessary as Ms G suggested a relative with whom she was happy for X to stay whilst officers completed their investigation. I also note that the Council’s records state that on the day of the allegation and medical examination Ms G is noted to have said she did not want X returning to her care.
26. Ms G says she did not consent to her daughter being placed with a relative under section 20 of the Children Act 1989 for five days. The Council says that X was not placed under section 20 and I agree this was not the case as Ms F suggested a relative with whom she was happy for X to stay rather than any formal section 20 placement seemingly having been discussed. So, no formal agreement was reached under section 20 and the placement was not made under section 20. The Council accepts that Ms G did not agree for this arrangement to last for five days and that it could have returned her to Ms G’s care earlier than it did had it tried to communicate with her using other means after it failed to successfully contact her by telephone. I therefore find that there was fault in the Council’s failure to take proper action to consider returning X to Ms G’s care before it did. I accept this caused both X and Ms G avoidable distress as it probably unnecessarily prolonged the period of time X was not living with Ms G. I use the word “probably” as Ms G had said she did not want X the previous day and I am unclear what her thoughts were by that time but nonetheless she was, at the least, denied the opportunity to reconsider this at that time.
27. The Council accepts that the social worker failed to pass on X’s prescribed medication on the day she began staying with her Ms G’s relative. I consider it was an oversight that the Council needs to ensure does not happen in future to other children in similar circumstances and the Council has already apologised to Ms G for this. As X’s medication was prescribed it seems likely that missing this may have also meant that X’s health needs were not met that day. In its comments to me the Council accepts that transport provided to take X to school meant she arrived late on three occasions during the period she was staying with Ms G’s relative. As the arrangement was short-term I consider any fault in making these arrangements caused minimal and very time limited injustice that does not justify action beyond the apology already given. I have already accepted that X may have been returned to Ms G’s care earlier had the Council managed to contact Ms G earlier using other means so I do accept also that the situation may have been entirely avoided had it done so. It does not appear that Ms G’s complaint to the Council included reference to X missing out on her usual after school activities. However, I would apply the same consideration to this: that any injustice was short-term and the result of an emergency situation but may have been almost entirely avoided had she returned home before the weekend.
28. My role is not to consider the merits of decisions properly taken. Ms G says the Council wrongly decided to make X a Child in Need under section 17 of the Children Act 1989 at a child protection case conference. It is not for me to consider the merits of the decision and, as a general point, this was a decision that the conference was entitled to make. Having considered the paperwork connected to the child protection case conference I would not consider there is evidence of fault in the way the conference considered the evidence or went about reaching its decision. There are therefore no grounds on which I could criticise the decision reached.
29. The Council accepts that it failed to consider Ms G’s complaints about these matters in a timely manner under the correct complaints’ procedure from August 2018. I agree that its handling of the complaint was very delayed and that this amounts to fault that caused Ms G injustice as she had to come to this office in order for the matter to be resolved and was denied the opportunity to have her complaint properly considered under all stages of the complaints procedure. I am unclear whether the Council accepted that it should have considered the matter under the statutory complaints procedure. The lack of clarity on this also amounts to fault and, for the sake of clarity on this now, I consider the matter should have qualified for consideration under the statutory procedure.

Agreed action

30. The Council has offered an apology and a payment of £500 to recognise its poor and inadequate handling of Ms G’s complaint. I consider this a reasonable sum to recognise the injustice caused by these failings and it should make this apology and payment to Ms G within one month of the final decision on this complaint.
31. The Council will make an additional payment of £200 within one month of the date of the final decision to recognise the avoidable injustice caused by X remaining with her relative over the weekend (including the late school starts and the missed social activities) when this may not have been necessary had officers tried an alternative method of contacting Ms G following the medical examination.
32. Within one month of the final decision on this complaint, the Council will update me on the action taken further to consideration with the social worker and social work manager to ensure that in future other forms of communication are tried with service users when they cannot be contacted by telephone in more urgent situations and how situations such as that with the medication not being passed on may be avoided.

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Final decision

33. There was fault in the Council’s handling of some matters during the period of its investigation of concerns about a non-accidental injury to Ms G’s daughter and in its handling of her subsequent complaint. This caused Ms G injustice and it will take the agreed action to recognise this and to improve future social work practice.

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Investigator's decision on behalf of the Ombudsman