Summary: there is fault in the Council’s handling of Ms B’s complaint about an initial child protection conference following an injury to her child. The Council will take action to remedy the injustice this caused Ms B by apologising and making a payment to her. It will also ensure that future complaints about case conferences are responded to properly under the correct complaints process.

The complaint

1. The complainant, whom I shall refer to as Ms B, complains that the London Borough of Bromley is at fault in relation to its handling of matters she complained to the Council about in February 2019. These relate to a child protection case conference convened to consider concerns following an injury to her baby, whom I shall refer to as Y. In particular she says:
1. the social work report for the case conference contained inaccuracies, particularly in reference to her mental health and the events around the injury, which need to be corrected;
2. participants in the case conference continued a discussion about the level of concern in the absence of Ms B and the Conference Chair and this seemed to unfairly result in one of the participants changing their view in support of a child protection plan when her view was not considered;
3. the social worker unreasonably suggested Ms B should attend a mindfulness course as part of the child protection plan in order to address mental health problems that were already under control and without discussing the recommendation with Ms B previously;
4. the minutes of the conference contain inaccuracies which need addressing including wrong information about advice about the care of Y and an inaccurate record of her response to being offered a course on safety; and
5. it failed to respond promptly or fully to her complaint about the conference and the minutes of this which she first submitted in February 2019.

Back to top

The Ombudsman’s role and powers

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. 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)

Back to top

How I considered this complaint

4. I discussed the complaint with Ms B and considered the written information she provided with her complaint. I made written enquiries of the Council and considered all the information before reaching a draft decision on the complaint.
5. 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.
6. I gave the Council and Ms B the opportunity to comment on my draft decision and took account of these before reaching a final decision on the complaint.

Back to top

What I found

What should have happened

7. Councils have a duty under the Children Act 1989 to make enquiries where they suspect a child is suffering, or likely to suffer, significant harm. If concerns are substantiated the Council may convene a child protection case conference. This is a multi-disciplinary meeting whose attendees decide what action is needed to safeguard the child. The conference may decide to make the child the subject of a child protection plan which details what action is necessary to reduce the risk of harm. Subsequent review child protection case conference(s) consider progress made and whether the child protection plan should be maintained, amended or discontinued. A core group of key professionals oversees and monitors the plan.
8. Councils usually have a process for dealing with complaints about child protection case conferences under their local child protection/safeguarding procedures. The complaints procedure is for people dissatisfied with the conduct or outcome of a child protection case conference and covers complaints about the way the conference was run, whether a child should have a child protection plan and decisions about the category of harm (physical abuse, neglect, emotional harm or sexual abuse). The decision of the conference cannot be changed using the complaints procedure but the complaints process can decide to, for example, decide that a conference did not follow proper procedures and recommend remedial action or to re-convene a conference to reconsider the decision and this may result in a different decision. The London Borough of Bromley says it follows The London Safeguarding Children procedures. Paragraphs 4.12.1 to 14.12.5 of these procedures state how the council will handle complaints about child protection case conferences. This confirms that complaints about the process of the conference or the outcome of the conference will be passed to the manager of the conference and the Council’s complaints manager. It says the outcome of the complaint will either be that a conference is reconvened under a different chair, that a review conference is brought forward or that the decision is confirmed with an explanation for this.
9. The Council’s corporate complaints procedure says that the manager of the service being complained about will investigate and provide a response within 20 working days. The procedure says that complicated matters may take longer but the Council will tell the complainant this if it applies in their case. The Council’s procedure states that if complainants are dissatisfied with the Council’s response they may complain to this office.

What happened

The referral and case conference

10. A hospital referred details of an injury to Ms B’s very young baby to the Council after Ms B took her to its accident and emergency department in late November 2018. The injury turned out to be a fractured bone which was the result of her falling off a bed. The Council completed enquiries into the injury and how this had happened and decided that an initial child protection case conference was required. The conference was arranged for December 2018.
11. A social worker wrote a report of her assessment of the concerns in December 2018. In her report the social worker provided details of the injury and the opinion provided by a doctor that it could have been an accidental or non-accidental injury and that the nature of the injury was consistent with a fall. The report notes that Ms B told staff that she had placed the baby on the bed on a number of occasions before the accident. In her report the social worker stated that staff at the hospital where Ms B took the baby following the injury observed that Ms B placed Y on the bed while she was there and that, even though Ms B was watching her baby whilst she was on the bed, they advised Ms B that placing the baby on the bed was not safe. Her report states the Ms B accepted she should not do this. The report assessed the concerns and the social worker recommended that Ms B’s baby should be made the subject of a child protection plan. The report was used for the child protection case conference.
12. The case conference went ahead in mid-December 2018. It was attended by a number of people including Ms B, the social worker, Y’s doctor, Y’s health visitor, a representative of a local children’s project and other family members. The notes of this conference detail the discussion that took place.
13. The summary given by the chair of the conference at the beginning of the meeting states that Ms B had been observed by hospital staff to place Y on the bed when she was in hospital when Y was born and that she was advised by staff not to do this. The notes go on to state “…yet Y sustained a significant injury as a result of Ms B doing just that”. The chair stated later on that that the accident had happened despite Ms B having been given advice that she should not place Y on a bed and that she was concerned about this.
14. The conference decided that Y should be made the subject of a child protection plan under the category of neglect. All of the attendees were asked to offer their view on the risks to Y following the discussion and on whether these indicated a need for a child protection plan. The chair is noted to have been of the view that a child protection plan was needed on the basis that the incident was an accident but had resulted in a significant injury to Y. The chair also noted that Ms B had been previously advised on the risks which had resulted in the accident so there should be a period of ongoing support and close monitoring. The health visitor also referred to the fact that Ms B had been previously advised not to place Y on a bed and that she did this again and the fall happened after this advice was given.
15. The conference drew up a support plan which included formalising:
• support from family members;
• Ms B to seek mental health support from her doctor; and
• Ms B to ensure that Y was taken to routine health checks and that treatment for any emergency medical situations were dealt with promptly.
16. The notes of the conference record that during the discussion the social worker asked the representative from the local children’s project about a mindfulness course it runs but that the officer from the project advised that he considered Ms B should not be overloaded with activities as she had a young baby to care for.
17. A review case conference took place in March 2019. The decision of that review conference was that a child protection plan was no longer required as there were no concerns about Y. A child in need plan was not put in place as Ms B did not agree to this. It was left that she would make contact if she needed support in the future.

Ms B’s complaint and its consideration by the Council

18. In late December 2018, having received the notes of the conference, Ms B emailed the group manager in the Council’s child protection conference team to say that there were matters arising from the minutes of the conference which she wanted to clarify and amend. These included:
• a correction about the exact nature of her mental health diagnosis; and
• a correction that the advice she received regarding safety measures regarding her baby was given after being advised about an incident and not before. She stated that she had followed this advice and it was not the case that she had failed to follow this advice as was implied by this incorrect account. She went on to say that the incorrect understanding of this may have affected the outcome of the conference and may merit discussion but, if not, correction in the notes of the discussion.
19. In January 2019, the Council officer responded stating the notes of the meeting could not be amended but agreeing she could append Ms B’s email detailing the errors and her concerns to the notes and send a copy to all those who attended the conference. She went on to ask for some clarification of the point Ms B had raised about the timing of the advice she was given about the safety measures referred to above. She told Ms B that the decision of the conference could not be changed but that the core group meeting and review conference could be used by her to demonstrate there were no longer concerns.
20. Evidence provided by the Council suggests that the points Ms B raised in this email were attached to the notes of the conference. The Council has also provided evidence confirming this was distributed to all those who attended.
21. Ms B responded confirming that the advice about not placing her baby on a bed was given after the incident and not before. She repeated that she was unhappy that this was incorrectly noted and that she was therefore concerned that this inaccuracy had negatively influenced the decision of the conference. She said she wanted this investigated. She asked how she could pursue this but there is no evidence that a reply was given to her by the group manager. It seems it may have been passed to the Council’s complaints team for a response under the corporate complaints procedure following a further undated letter from Ms B.
22. I am unclear when Ms B submitted her letter of complaint but it does not refer to the review case conference so I assume was submitted before that. Broadly the complaint was that:
• the account of her mental health diagnosis was inaccurate and the account of the advice given was wrong (as detailed above);
• the conduct of the case conference itself was unfair as it seemed that, during her absence from the room, one of the attendees changed their mind about the need for a child protection plan having previously said one was not needed but then saying it was. She also said this conversation was unreasonably not noted in the minutes of the meeting;
• the suggestion of a mindfulness course had not been discussed prior to the conference meeting; and
• a request to amend the minutes of the conference (as referred to above).
23. The Council provided a response to Ms B’s complaint in April 2019. In it the Council apologised for the delay in providing a response. The Council also reiterated that the points Ms B raised would be recorded on Y’s file to be read in conjunction with the assessment. It said that the information she had provided about her mental health diagnosis and medication would be noted on Y’s file. The officer who provided the response said that a professional who made the referral to the children’s services team had stated that Ms B “…admitted has often put baby on edge of bed”. The officer said she suggested that Ms B should contact the referrer (I assume this means the hospital staff) to discuss this further. She said that the issues Ms B raised about the services provided in relation to the case conference and minutes of this were the responsibility of the Quality Assurance team who had responded separately (this appears to refer to the response provided by the group manager in the case conference team).

The Council’s response to my enquiries

24. In its response to my enquiries the Council stated “After the participants had had their discussions and submitted their respective views on the appropriate outcome of the Conference, Ms B was understandably upset and left the room. The Chair went to be with her. Whilst they were out of the room, although the Conference had effectively concluded, a further conversation arose amongst those remaining, started by…during which it suddenly became apparent to Mr X (the representative from the local children’s project) that he had misunderstood the timeline of the incidents involving Y. This raised his level of concern to the extent that when the Chair and Ms B returned, he indicated that he wished to change his position to supporting a Child Protection Plan”. The Council goes on to say that “this change of position came about purely as a result of a specific fact being confirmed to Mr X, rather than (for example) the views of or the pressure applied by another participant. Secondly, again, given the views of the other participants this did not affect the outcome of the Conference”.
25. The Council does not accept the minutes were inaccurate stating they were a summary rather than a verbatim record and repeating that it agreed to attach Ms B’s subsequent communication to the minutes on the system and to send a copy to all the agencies who attended the conference.
26. In relation to the handling of Ms B’s complaint the Council says it recognised that elements of Ms B’s complaint were never properly responded to by the group manager of the conferencing team. The Council says that there is now a new head of that service and that the head of the complaints service has now put in place a procedure to identify where individual services who have not provided their contribution to complaints that involve different services. The Council says it is unable to explain why there was a delay in it providing a response to Ms B’s complaint.

Is the Council at fault and did this cause injustice?

27. The information provided to the conference and recorded in the notes of the initial conference meeting does not accord with that in the social work report. The social worker’s report says that the advice about not placing the baby on the bed was given to Ms B when she did this at the hospital after she took Y to hospital following the accident, not that this advice was given to her before the injury to Y. In that respect I agree with Ms B that the conference appeared to be considering inaccurate information as the information shared stated she had ignored advice already given when in fact the advice was given after the accident. Ms B is clear that she did follow the advice after it was offered. Given the Council’s comments about Mr X changing his mind about his recommendation because he had previously misunderstood “the timeline” of incidents related to the accident, it appears possible that he changed his view based on this wrong information. I consider the provision of this wrong information amounts to fault. The Council had an opportunity to put this right after Ms B complained but it did not do so. I consider this fault caused Ms B injustice in the form of avoidable frustration, distress and uncertainty though I cannot definitely say that, if the conference members had been provided with the correct account, that it would have reached a different decision. This is because there were a number of factors detailed that influenced the decision and not only the concern about the alleged failure of Ms B to follow previous advice though this clearly did have some influence.
28. I do not consider that the social worker unreasonably suggested Ms B should attend a mindfulness course as part of the child protection plan. The notes suggest the social worker raised the possibility of her attending such a course but that it was not pursued. This does not amount to fault.
29. The handling of Ms B’s complaint by the Council has been poor. The issues she raised were not dealt with effectively or conclusively either by the group manager of the conference team or under the corporate complaints procedure. The use of both procedures has been unclear and confusing. The process detailed in the London Safeguarding procedures was not properly undertaken or completed. The final request by Ms B to investigate the incorrect information about the advice she was given by the hospital was not responded to by the group manager of the conference team and a different issue was addressed under the corporate complaints procedure. The poor handling amounts to fault and this caused Ms B injustice in the form of avoidable distress. It also denied her the opportunity to have the matter resolved much earlier and possibly before her daughter was removed from a child protection plan in March. It also compounded the injustice caused by the original fault in the wrong information being provided in the conference.

Agreed action

30. Within one month of the final decision on the complaint the Council will:
• apologise to Ms B for the injustice caused by the faults identified;
• append my final decision on this complaint to Y’s children’s services file. It will also pay Ms B £300 to recognise the avoidable frustration, uncertainty and distress she was caused by this wrong information being given to the conference and placed on Y’s file; and
• pay Ms B a further £200 to recognise the Council’s delayed and inadequate handling of her complaint.
31. The Council will also ensure that staff who are tasked with dealing with complaints about case conferences are adequately trained and comply with the requirements detailed in the London Safeguarding Children Procedures when completing their consideration of these. I recognise that the Council says it has changed its processes and there has been a change in the head of the relevant service but the Council will provide me with evidence of the specific changes it has put in place to ensure complaints about case conference will be properly dealt with in future. It will provide me with this evidence within two months of the date of my final decision on this complaint.

Back to top

Final decision

32. There is fault in the Council’s handling of Ms B’s complaint about the initial child protection conference, particularly its response to her concerns that inaccurate information was provided in the conference. The Council will take the action detailed above to remedy the injustice this caused Ms B and also ensure that future complaints about case conferences are responded to properly under the correct complaints process.

Back to top

Investigator's decision on behalf of the Ombudsman