Summary: Mrs C says the Council has not adequately remedied injustice that the Council caused her daughter, X, while she was in its care. She also says the Council did not fully investigate some of her allegations against the Council. She says Council failures have caused injustice to X who was put at risk of exploitation and have also caused her injustice, in the form of distress. There was no fault with the way the Council investigated her complaints. The investigation was thorough but the remedy offered was inadequate. We have recommended a further remedy for the fault identified by the Council.

The complaint

1. The complainant, who I have called Mrs C, says the Council is at fault for matters occurring while her daughter, who I have called X, was in the Council’s care. She says it did not:
1. Adequately remedy injustice arising from fault which it identified and accepted was its responsibility, which occurred when X was in its care; or
2. adequately investigate the parts of the complaint it did not uphold.
2. Mrs C says this has caused injustice to her, Mr C and X because X has missed out on therapy. Mr and Mrs C were caused great distress, and Mrs C was put to considerable time and trouble in pursuing the Council.

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The Ombudsman’s role and powers

3. We cannot investigate late complaints unless we decide there are good reasons. A late complaint is one made more than 12 months after something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
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 have called 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)
5. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
6. If an investigation under stage two of the statutory investigation procedure is properly conducted and is not flawed by fault, we do not reinvestigate the facts that led to the complaint again. Our role is limited to reviewing the remedy.
7. 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)
8. 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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How I considered this complaint

9. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
10. Mrs C and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

What should happen

Councils’ duties to children

11. Councils have a duty to safeguard and promote the welfare of children in their area who are in need by providing a range and level of services appropriate to those children’s needs.
12. If it seems to a council that a child in its area is at risk, then it must investigate to see whether protective action is required.
13. Where it appears that a child is at risk, whether from the parents or because they are beyond parental control, councils can apply to the courts for a care order.
14. Once in care, a child’s case should be kept constantly under review. An Independent Reviewing Officer (‘IRO’) should be appointed to their case. The IRO should chair reviews of the care provided and to make sure that the care provided follows the care plan and respects the child’s rights. The IRO Handbook, which IROs must follow, says IROs must:
• promote the voice of the child;
• ensure that care plans are based on a proper assessment of a child’s needs;
• make sure that each child knows how they can get hold of an advocate;
• act as a safeguard against children staying in care longer than necessary or not getting the services they need;
• ensure children understand changes to their care plan; and
• ensure the local authority is a good ‘corporate parent’ to children in care.

The statutory complaints procedure

15. The law sets out a three-stage procedure for councils to follow when looking at complaints from and about children using their children’s 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 of the outcome.
16. If a council has investigated something under this procedure, the Ombudsman would not normally re-investigate it unless we consider the investigation was flawed in some way. However, we may look at whether a council properly considered the findings and recommendations of the independent investigation.

What happened

Background

17. Mr and Mrs C’s adopted child, X, was born and lived until adoption in another council area. Mr and Mrs C adopted X and her brother, Y, more than a decade ago. X is now an adult.
18. Mr and Mrs C were soon concerned about X’s development and behaviour from the beginning. They approached X’s birth mother’s home council for assistance shortly after the adoption was finalised. Shortly after that, when X became the Council’s responsibility, Mr and Mrs X requested assistance from it. Mrs C says the Council failed to coordinate with the birth mother’s council.
19. Later, when X was in her teens, she established contact with members of her birth family which seems to have been unsettling for her and disruptive of Mr and Mrs C’s family. X also began to meet men online. She would frequently abscond.
20. In 2016, the relationship between X and Mr and Mrs C deteriorated and, on one occasion, Mrs C asked the Council to take her into care. They continued to live together but the relationship continued to deteriorate and X continued to abscond.
21. In early 2017, X was diagnosed with an autism spectrum disorder. The Council referred X to a specialist who made various recommendations for her care in a report (‘the medical report’). He recommended that, if X was willing to engage, she should receive psycho-sexual therapy from someone familiar with autism spectrum disorders. He also recommended that, if X were to be taken into care, it would be helpful for her to live in single gender accommodation.
22. For some time, X continued to live at home but matters did not improve and the Council applied for an interim care order in mid 2017. The Council’s application was successful, At the same time, the Council approved a care plan for X which included recommendations from the medical report. After this, X was taken into care. She initially went into foster placements locally but later at other residential care placements nationwide.
23. Mr and Mrs C remained concerned about X. They were concerned that she was not protected by the Council during these placements. They believed she had formed inappropriate attachments to males and was put at risk of physical harm and exploitation.
24. The Council applied for a final care order in late 2017. It was granted by the Court. Mr and Mrs C say the judge stated that they should be involved in future ‘Looked After Child’ meetings about X. They say the Council repeatedly failed to involve them. The Council said this was because X had said she did not want them involved.
25. In early 2018, X moved to a semi-independent living facility in London. She absconded on several occasions. She then moved to another semi-independent living facility. Mr and Mrs C were concerned that X was given freedom to mix with males and even allowed to invite them back to her room. She began a relationship with one man who, she later said had abused her. She became pregnant. Shortly thereafter, X turned 18.
26. In early 2018, Mrs X wrote to the Council about what she saw as the many failures in X’s care. The Council responded in May 2018. It said it had attempted to provide the care and treatment set out in the care plan but, because X had been moved on several occasions, this had not always proved possible. It said it had now referred X for the required therapies near to her current placement. The facility had said it would either provide the therapies she needed itself or commission them from a suitable provider.
27. The Council accepted that it had failed to invite Mr and Mrs C to an important meeting about X’s care. It also accepted that it had failed to invite Mr and Mrs C to a Looked After Child meeting in October 2017. It also accepted that X’s education had suffered but said this had been because she not been willing to engage with teachers.
28. The Council also accepted that it had moved X to a mixed-gender facility when the medical report had recommended a single sex setting but said this had been because the Council had not been able to find suitable single sex accommodation and also because X’s needs had changed as she got older. As she approached 18, she would have to learn to live independently and this would help.
29. Mrs C complained formally to the Council in August 2018. She said she had learned X was pregnant. The Council responded three weeks later. The Council said X had asked that Mr and Mrs C should not be informed of her circumstances and it could not, therefore, respond to her letter fully. However, it would provide what responses it could.
30. In her letter, Mrs C raised various points. I have set out the most important below with the Council's response:
1. Why had the Council exposed X to the risk of pregnancy? – The Council was not aware that it had done so. The Council could not restrict X’s liberty without a court order. Legal advice suggested that the court would not grant one. It did what it could to protect her.
2. Why had the Council not kept her in a single gender children’s home until she was 18? – The Council said the medical report had not explicitly stated that this was necessary. Also, the report was written in early 2017 when X was 16. A later review had decided that it would be best to prepare X for adulthood in mixed-gender accommodation.
3. Was the Council aware that the report prepared about X had recommended semi-independent supported living accommodation after she turned 18? -The Council said it was aware and was attempting to find such accommodation.
4. Why had her current accommodation allowed X to meet men and then allowed these men into X’s room unaccompanied? - The Council said it was unable to respond to these points because of data protection legislation.
5. Why had X not received therapy she needed? - X had refused to engage with the therapies on offer. The Council could not force her to do so.
6. The Council had placed X at risk of sexual exploitation by placing her in mixed sex accommodation. – The Council said it had not ignored the report which had recommended but not stipulated single sex accommodation. It was working with professionals to provide the support X needed.
7. The IRO had failed to ensure X was safe and had formed a view that X was a rebellious teenager. – The Council said that the IRO had done her job in line with all the relevant legislation including the Human Rights Act, the Children Act and the Equalities Act.
8. The Council was responsible for ‘serious failings of deliberate neglect’. – The Council denied that this was the case but said it would hold a review of all Council actions. If failures were found they would be addressed. The Council would continue to support X until she was at least 21.
31. Mrs C was not satisfied with this response. She responded the next day quoting at length from the medical report.
32. On the advice of a senior officer, the Council then considered Mrs C’s complaints under stage two of the statutory complaints procedure. The investigation was completed in December 2018. Below, I have set out Mrs C’s agreed heads of complaint with the conclusion reached on each after the stage two investigation:
1. Council portrayed Mr and Mr C as abusers of X; - Upheld.
2. Council failed to ensure that appropriate specialist therapy was available for X while she was in Council care; - Upheld.
3. Council failed to safeguard X while she was in their care; - Partly upheld. The investigation found that in the first four places where X had been accommodated, the care provided had not been suitable and had put X at risk. However, in the final placement, the placement had been suitable.
4. The Council’s decision to place X in a semi-independent placement in spring 2018 was inappropriate as she had an autism spectrum disorder and was at risk of exploitation. The medical report had recommended she should be placed in single sex accommodation. ; - Not upheld. It had been only a recommendation to place X in a single gender unit and, as she was nearing 18 and would soon be free to associate freely shortly, and because she didn’t want to stay in a single gender unit, the Council had decided differently.
5. Council failed to keep Mr and Mrs C adequately informed of the arrangements for X’s care; - Upheld
6. Council victimised Mr and Mrs C; - Not upheld
7. Council failed to implement the care plan issued in October 2017; - Partially upheld
8. Council failed to provide X with adequate support to help her with her GCSEs; - Upheld
9. Council failed to hold a Care Act assessment which took proper account of X’s vulnerabilities and failed to share the assessment with Mr and Mrs C; - Not upheld; and
10. Council dealt with the complaint under stage 2 of the statutory complaints procedure against her wishes and used this to avoid answering her questions. – Not upheld.
33. Mrs C had several desired outcomes from the investigation. These are listed below with the Council’s responses:
1. A full investigation into her complaints. – The stage two investigation was a thorough investigation
2. The Council should act to safeguard X and consider whether its failure to do so should be referred to the police. – As the investigator did not uphold Mrs C’s complaint 3 (above), he said he would not make recommendations about her current safety as he did ‘not consider the failings identified were so egregious as to warrant referral to any other agency’.
3. A remedy for both Mr and Mrs C and for X which ‘should include but not be limited to, a written apology’. – The investigator recommended that the Council should apologise for the faults he had found.
4. X’s Care Act assessment to be reviewed or done again. – As the investigator had not found fault on complaint 9, he would not recommend this.
5. The Council should support X during her pregnancy and safeguard her and her baby. – The investigator said that he had no doubt that the Council would do this but suggested it might want to reassure Mrs C that this was the case.
34. The investigation also made various recommendations of its own:
1. Adequate steps should be taken to ensure that carers looking after children or young people for the Council are aware of and act in accordance with the care and placement plans.
2. There should be effective liaison between the social care and fostering teams for young children in foster care.
3. Parents, the young person and the IRO should be properly consulted in relation to planned placements and at the termination of placements.
4. Social workers to visit proposed placements before they take place. Consideration to be given to arranging introductory visits for parents and young people.
5. Parents should be informed in writing when their child is placed (other than in an emergency).
6. Parents should be informed when a child goes missing from a placement.
7. Parents notified of changes of social worker or social work team and consideration given to arranging transfer meetings.
8. There should be effective liaison between social work teams and the commissioning and improvement service if there are concerns about the ability of a commissioned organization to meet the needs of a young person.
9. Consideration should be given to involving the commissioning and improvement service whenever there are strategy meetings or discussions or professionals’ meetings about the child.
35. In its adjudication letter, the Council accepted all the findings of fault and recommendations. It apologised to Mr and Mrs C for the fault found.
36. Mrs C requested a stage 3 review challenging the investigator’s decisions not to uphold the final part of complaint 3 and complaints 4, 6 and 7 and 10 as set out in paragraph 32 above.
37. She also again requested that the panel should:
1. Consider whether the Council’s actions had complied with the relevant legislation, guidance and procedures. And whether she and Mr C had been victimized.
2. Consider whether the Council had been ‘guilty of neglect and cruelty’ by exposing X to risk.
3. Consider whether the IRO and the Council were guilty of neglect and cruelty by exposing X to risk of abuse.
4. Consider whether Council and IRO were guilty of neglect and cruelty by placing X in semi-independent accommodation without providing her with the necessary therapy first.
5. Provide Mr and Mrs C and X with written apologies for the fault found.
6. Instruct the Council to update all its systems within 60 days with accurate information.
38. The Council held a stage three review which found that, in addition to the previously upheld complaint:
• Complaint 4 should be upheld because the Council had not followed due process during the process of deciding to move X. It had not contacted Mr and Mrs C. and
• Complaint 10 should also be upheld. The panel found that the way in which the process had been completed was unfair to X who had not wanted to share her information with Mr and Mrs C. The effect of escalating to stage 2 was that this wish was ignored,
39. The panel asked the Council to reflect on having shared X’s information with Mr and Mrs C. It further recommended that the Council should reflect on how it would have made the proceedings accessible to X who had some learning difficulties. It did not recommend any of the outcomes that Mr and Mrs C had requested as these were not justified by the findings.
40. The Council accepted the review panel’s findings and recommendations.
41. Mrs C was not satisfied with this response. She complained to the Ombudsman.

Was there fault causing injustice?

42. Where the statutory complaints process has been completed, the Ombudsman does not reinvestigate unless there is evidence that that investigation was flawed in some way. I have seen no evidence that it was. The investigation report is clear, thorough and applied the relevant law and guidance correctly.
43. The report explicitly considered Mrs C’s other heads of complaint and found that the evidence did not justify findings of fault. I cannot find fault with it because Mrs C disagrees with it. There must be errors in the way it was conducted.

Adequate remedy for injustice

44. The stage two investigation and stage three review found the Council to be at fault as set out above. Mrs C does not feel that the Council’s remedy of an apology to her and Mr C adequately remedies the injustice she has suffered. My view is that the actions the Council has taken so far do not fully remedy the injustice caused to X or Mrs C and her family. I have set out below the injustice caused and proposed remedies in line with our guidance on remedies.

Injustice to X

45. Lack of therapy. The Council accepts that it failed to provide therapy which had been recommended in the doctor’s report prepared in September 2017. Therefore, the Council should determine whether therapy is still required and, if so, arrange for her to have it.
46. Exposure to risk of harm. The stage two report identified that, at various times during the period when she was legally in the Council’s care, X was put at risk through Council fault. When placed at foster placements, the Council failed to inform foster parents of vital information which meant that the foster carers allowed her to abscond and put herself at risk of harm.
47. A Council officer accepted that, after going into care, X should have been put into a therapeutic environment rather than foster care. She remained in foster care and absconded the next day. She was then placed in another foster placement and absconded from there several times. Later, X was placed in a children’s home in another city for two months where she formed a friendship with a young offender and, again, absconded and put herself at risk.
48. She was then placed in a single gender residential school in the countryside. However, this was not seen as a suitable option as it could not provide for X’s needs. Nonetheless, she stayed there for several months. The Council then moved her to a semi-independent living placement before she had received any of the psychosexual therapy that had been recommended for her. This, again, placed her at risk. Overall, there were numerous failures to keep X safe and in line with the Ombudsman’s guidance on remedies, I consider that £1,500 would be a suitable remedy for this.
49. Mrs C says that the Council was wrong then to place X in a further semi-independent living placement because it was not single gender and because X was at risk there too. However, the Council was not found to be at fault for placing X in this placement because, by that point, X was 17 and, therefore, her views were of increasing importance to decision makers. Although the medical report had recommended single gender accommodation in early 2017, the Council was faced with a complex situation It could not confine X against her will and she was likely to abscond from a single sex facility.
50. Impact on life chances: The Council accepts that it failed to provide an adequate education to X during the time when she was in its care. As a result, her education suffered. She had intended to take three GCSEs but, due to a lack of suitable staff, she received no tuition in two of those subjects. Ultimately, she decided not to take any of them. This and the other disruption she suffered during this time, severely affected her life chances and I consider that £1,500 would be a suitable remedy.

Injustice to Mrs C and family

51. The Council’s failures caused Mrs C severe and prolonged distress lasting for well over a year. This would have been a stressful time even without Council fault. However, after the care order was granted in mid-2017, the Council’s failures, resulting in X going missing numerous times, and the failure to provide X with suitable care and therapy, caused additional stress to Mrs C and the rest of the family. I have therefore recommended that the Council should make a payment of £2,000, to be divided equally between Mrs C, Mr C and their other child, in recognition of that distress.

Systemic failures

52. The complaint has also highlighted seemingly systemic failures in the Council’s children’s services department.
53. I have therefore made various recommendations of service improvements below.

Agreed action

54. The Council has agreed that, within two weeks of the date of this decision, it will:
1. write to Mrs C and apologise for the distress caused and the time and trouble she was put to and pay her £2,000; and
2. Write to X and apologise for the fault found during the statutory complaints procedure, stages two and three. It has agreed to do so in a way which is mindful of the concerns of the chairman of the stage 3 review and to offer her the therapy recommended in the psychiatrist’s report. It has agreed to pay her £3,000.
55. The Council has agreed that, within two months, it will write to the Ombudsman confirming that it has taken steps to do the following:
1. Review staff training needs on the application of statutory guidance for complaints.
2. Review staff (including independent reviewing officers) training needs on the application of statutory guidance for care planning, placement and case review.
3. Review staff training needs on the application of statutory guidance for transition to adulthood for care leavers.

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Final decision

56. I have found the Council to be at fault. I have recommended a remedy to which the Council has agreed. I have closed my investigation.

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Investigator's decision on behalf of the Ombudsman