• The complaint
• The Ombudsman’s role and powers
• How I considered this complaint
• What I found
• Final decision

The Ombudsman's final decision:

Summary: Ms B and Mr C complain about the way the Council handled a safeguarding referral about Ms D’s (Ms B’s daughter) children. The Ombudsman has found no evidence of fault.

The complaint

1. Ms B and Mr C are complainants acting on behalf of Ms D, who is Ms B’s daughter. Ms B and Mr C complain about the way in which the Council handled a referral about Ms D’s children. Ms B complains the Council failed to help her daughter, Ms D, when it removed her younger two children from her care and placed them with their father, Mr E. Ms B feels the lack of support given to Ms D by the Council, and the separation from her children, led to Ms D taking her own life in August 2018.

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The Ombudsman’s role and powers

2. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), 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. 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 have spoken to Ms B and Mr C, and considered the information they have provided in support of their complaint.
6. I have considered the Council’s response to my enquiries, which includes confidential information I am unable to share with Ms B and Mr C or refer to in this decision.
7. I have also considered the Council’s procedures and the statutory guidance -Working Together to Safeguard Children 2015.
8. Ms B, Mr C and the Council have received a confidential draft of this decision statement to comment on. I have considered the comments received before issuing the final decision.

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What I found

Children Act 1989, section 47

9. Where a local authority has reasonable cause to suspect a child in its area is suffering, or is likely to suffer, significant harm, it has a duty under section 47 to make enquiries to enable it to decide whether it should take any action to safeguard or promote the child’s welfare.
10. In carrying out these section 47 duties, the local authority has the power to call on other bodies to help with its enquiries, including the police and relevant health and education professionals.
11. If, following a referral and an initial assessment by a social worker, a multi-agency strategy meeting decides that the concerns are substantiated and the child is likely to suffer significant harm, the local authority convenes an Initial Child Protection Conference.
12. The Initial Child Protection Conference decides what action is needed to safeguard the child. This may include recommending the child should be subject to a Child Protection Plan.
13. If the child becomes subject to a Child Protection Plan, there will be one or more Review Child Protection Conferences. The conferences are to consider progress on action taken to safeguard the child(ren) and whether the Child Protection Plan should be maintained, amended or discontinued.
14. The Council’s own guidance for safeguarding children of parents who misuse substances and/or have mental health problems states Children Social Care should engage with relevant colleagues involved in meeting the needs of parents. These colleagues should be invited to contribute and attend child protection conferences and core group meetings, so all staff involved work collaboratively to ensure the safety of the child(ren).

What happened

15. In late December 2017, the Council received a safeguarding referral from the police. This was following an incident involving Ms D and one of her children, Child Y.
16. The Council took immediate steps to ensure Ms D’s two other children, Child X and Child Z were safe by placing them in the care of Ms B and her partner Mr C overnight. Child Y stayed with his father. The Council also commenced child protection enquiries under section 47 of the Children Act.
17. The Council held a strategy meeting and devised a safety plan for the care of all three children over the Christmas period. The children were placed with their father.
18. The outcome of the Initial Child Protection Conference was that all three children were at risk of harm if they remained in their mother’s care. The Council also noted that Ms D was seeking help with her physical and mental health conditions and alcohol misuse. Ms D was able to have supervised contact with her children while they stayed with their father and saw them almost daily during this time.
19. The Council held monthly core group meetings to monitor the children and Ms D’s progress. Ms D attended the first three core group meetings held in February and March 2018. Ms D was supported at each meeting by a member of the Drug and Alcohol Team. The Council noted Ms D was engaging with support services and was keen for the children to return to her care. All three children stayed with their father, Mr E, until April 2018, when Child X returned to live with Ms D. The Council assessed the risk of harm in Child X returning and were satisfied there were appropriate measures in place to keep them safe.
20. In April 2018, Ms D attempted to take her own life and was admitted to hospital. Child X moved back in with Mr E and the other two children shortly afterwards. Ms D started to receive support from a Community Psychiatric Nurse (CPN). The Council held core group meetings in May, June and July 2018, which Ms D did not attend. The Council decided all the children (including Child X) should remain in Mr E’s care, while Ms D continued to have supervised contact with them and received help from mental health services.
21. In August 2018, Ms D sadly died by suicide.

Analysis

22. Ms B and Mr C have complained the Council failed to provide proper support to Ms D when it removed the children from her care and this in part led to her death.
23. I have a great deal of sympathy for Ms B, Mr C and the rest of Ms D’s family. Ms D’s death has clearly been very distressing for everyone involved. I can appreciate Ms B and Mr C’s desire to know more about what happened and the Council’s actions.
24. Ms B and Mr C do not have parental responsibility for Ms D’s children. This means I am unable to share anything about how the Council considered the safeguarding referral it received about Ms D’s children or the action it took as a result.
25. I have however examined a considerable amount of evidence from the Council. This includes records of the all the interactions it had with Ms D and her children. I am satisfied the Council followed statutory guidance when it decided to place the children in their father’s care and the monitoring it undertook as matters progressed.
26. The Council ensured it involved colleagues from the adult support services Ms D was accessing and that she was supported by these colleagues at all the core group meetings and child protection conferences she attended. Again, I am satisfied the Council followed its own procedure by working collaboratively with other services to ensure the safety of the children.
27. I realise none of this alleviates the grief and distress Ms B and her family have and are still experiencing. I hope however, that my independent review gives Ms B and Mr C some reassurance that the Council’s handling was in line with statutory guidance.

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Final decision

28. I have completed my investigation and found no fault in the Council’s handling.

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Investigator's decision on behalf of the Ombudsman

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