London Borough of Lewisham (20 001 265)

Category : Children's care services > Child protection

Decision : Upheld

Decision date : 02 Sep 2021

The Ombudsman's final decision:

Summary: We upheld a complaint from Ms D about actions the Council took to safeguard her, and the support it offered her as a care leaver. We found the Council carried out an inadequate assessment and failed to help Ms D to gain access to and make best use of services. These faults create uncertainty for Ms D about what effect further support might have had on her well-being. The Council agreed to apologise and offer a payment to Ms D to remedy this injustice. It will also offer her help to access services.

The complaint

  1. Ms D complains the Council failed to take action to safeguard her when she disclosed abuse from her mother when she was a child. She says this affected her physical and mental health. She also says the Council has failed to support her to recover from the abuse. She would like an explanation for the Council’s decisions, an apology and financial compensation. She would also like the Council to commit to supporting her ongoing therapeutic and medical needs.

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The Ombudsman’s role and powers

  1. 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)
  2. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended). I have exercised discretion to consider events which occurred in 2013 due to the age and vulnerability of the complainant meaning she could not reasonably be expected to have complained to us sooner.
  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)
  5. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children's Services and Skills (Ofsted).

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How I considered this complaint

  1. I have considered the complaint made by Ms D and the documents she provided.
  2. I considered the Council’s comments about the complaint and the documents it provided in response to my enquiries.
  3. Ms D 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

Law and guidance

Assessing children in need

  1. The Children Act 1989 places duties on councils to provide services to children in need to safeguard and promote their welfare. A child in need is a child who is unlikely to achieve or maintain a satisfactory level of health or development without the provision of services. Councils carry out assessments of the needs of individual children to determine what services to provide and action to take.
  2. The government published guidance, Working Together to Safeguard Children, in 2010 and updated it in 2013, 2015 and 2018. The guidance sets out the legal requirements and expectations on individual services to safeguard and promote the welfare of children.
  3. Working Together to Safeguard Children (2013) said the purpose of an assessment is:
    • to gather important information about the child and their family;
    • analyse their needs and the nature of any risk to the child;
    • decide whether the child is a child in need or is suffering or likely to suffer significant harm; and
    • provide support to address those needs to improve the child’s outcomes and make them safe.
  4. The guidance says a good assessment investigates the child’s developmental needs; the parents’ capacity to respond to those needs; and the impact and influence of wider family, community and environmental circumstances. It is important the impact of what is happening to the child is clearly identified. The guidance says assessments for some children, including young carers, will require particular care.
  5. Each child should have an individual assessment to respond to their needs and understand the impact on them as an individual. Councils should see children alone wherever possible and ascertain their wishes and feelings about any services to be delivered.
  6. Assessments should draw together relevant information gathered from the child and their family and from relevant professionals including teachers and health professionals.
  7. The guidance says: “A desire to think the best of adults and to hope they can overcome their difficulties should not trump the need to rescue children from chaotic, neglectful and abusive homes.” It says social workers should reflect the latest research on the impact of neglect and abuse when analysing the level of need and risk faced by the child and reflect this in the case recording.

Looked after children

  1. A child may become looked after either because they are subject to a care order or because they have been accommodated voluntarily under Section 20 of the Act.
  2. Section 20 of the Children Act 1989 says councils should provide accommodation to any child in need within their area who needs it, because:
    • there is nobody with parental responsibility to care for them;
    • they have been lost or abandoned; or
    • the person who has been caring for them being prevented from providing suitable accommodation or care.
  3. Councils cannot accommodate a child under Section 20 if a person holding parental responsibility objects and is willing and able to care for the child or arrange care for the child.
  4. A council’s duties are similar regardless of which route a child has taken to become looked after. They include:
    • Maintaining a care plan which sets out the long-term plan for the child, details of their placements, contact arrangements, personal health and education plans and contingency planning.
    • Holding looked after child review meetings at least every six months.
    • Appointing an Independent Reviewing Officer (IRO), a qualified and experienced social worker whose role is to ensure the council is meeting the child’s needs and their voice is being heard.
  5. The legal status of children who are the subject of a care order is not affected by detention under the Mental Health Act. The responsibility of councils to promote the welfare of looked-after children who are so detained remains. That includes its responsibilities to maintain and review the child’s health plan as part of his or her care plan.
  6. Councils have a general duty when looking after a child to safeguard and promote their welfare. This duty underpins all activity by the council towards looked after children and care leavers. This duty has become known as ‘corporate parenting’. In simple terms, this means the collective responsibility of the council, elected members, employees, and partner agencies, to provide the best possible care and safeguarding for looked after children and care leavers. It includes promoting the mental health and well-being of those children and young people and helping them to gain access to and make best use of services provided by the council and its partners. (Children Act 1989, section 22 and ‘Applying corporate parenting principles to looked after children and care leavers’ Statutory Guidance 2018)

Care leavers

  1. The Children Act 1989 places duties on councils to provide ongoing support for children leaving care. These duties continue until they reach age 21. If the council is helping them with education and training, the duty continues until age 25 or to the end of the agreed training (which can take them beyond their 25th birthday).
  2. Councils should appoint each care leaver with a personal adviser, and each care leaver should have a pathway plan. The personal adviser will act as a focal point to ensure the care leaver is provided with the right kind of support. The pathway plan should be based on a thorough assessment of the person’s needs. Plans should include specific actions and deadlines detailing who will take what action and when. They should be reviewed at least every six months by a social worker.
  3. Pathway plans should continue for all care leavers continuing in education or training. The plan should include details of the practical and financial support the council will provide.
  4. The guidance accompanying the Act says that when young people leave their care placement the council must ensure their new home is suitable for their needs and linked to their wider plans and aspirations. Moving directly from a care placement to living independently is often too big a step for young people. It is therefore good practice for councils to commission semi-independent and independent living options with appropriate support.
  5. The government has issued guidance called ‘Promoting the health and wellbeing of looked after children’. This says some children who cease to be looked after will have continuing health needs that need ongoing treatment. Health professionals and social workers should ensure there are suitable transition arrangements in place so the child’s health needs continue to be met. They should ensure that care leavers have, or know how to obtain, the information they need about what health services, advice and support are available locally to meet their needs.
  6. Leaving care services should ensure that health matters are included as part of the young person’s pathway planning. Care leavers with complex needs may transfer directly to adult services and the pathway plan will need to ensure this transition is seamless and supported. For care leavers who do not need to receive support from adult services, their personal adviser should ensure that all other forms of support are identified and facilitated as appropriate.

What happened

Events in 2013

  1. Shortly before the end of the school year in 2013, when they were 12, Ms D and her sibling told their school they were being hit and threatened by their mother. At the time, they had been identified as young carers because of their mother’s disability. The Council’s young carers support team had expressed concerns about Ms D’s self-esteem and change in behaviour over the previous year. The Council decided to carry out an assessment. Two weeks later, a social worker arranged to visit the family at home.
  2. In a meeting with their manager following the home visit, the social worker said Ms D’s mother had dismissed the allegations at first but later confirmed she had hit the children. The manager noted this appeared to be a one-off and the mother had signed a written agreement to prevent any further incidents.
  3. The social worker emailed the school and said she would arrange for a support service to work with the family which should be in place by the start of the new school year.
  4. The social worker completed her assessment the following day. She recorded she saw Ms D and her sibling individually and they reported their mother hit them with implements, pulled their hair and slapped them. Neither child could describe “the last incident or any incident of physical chastisement” but they were consistent about the events which had occurred. The social worker recorded the children’s mother denied hitting the children but later admitted to using implements to ‘touch’ them to get them to hurry up, or if they misbehaved. The social worker noted the mother had ‘agreed not to hit them anymore’ but there were some behavioural and relationship concerns to be resolved.
  5. In her analysis the social worker said Ms D’s mother’s care of the children was satisfactory and she had agreed to work with a support service to address the identified issues. She noted her mother had admitted hitting the children but had minimised this. She said while further intervention was required, it could be achieved by a family support service rather than by children’s social care. A manager signed off the assessment and noted their agreement with the social worker’s analysis and recommendations.
  6. The social worker closed the case the following week. On the same day, she emailed the family’s GP. She said as Ms D’s mother had agreed to a referral to a family support service and the Council was unlikely to take further action unless further incidents occurred. She asked the GP to provide information about the family. There is no response or follow up on the Council’s records.

Support from the Council

  1. Ms D became a looked after child in 2016. She attended a local hospital with concerns about her mental health and said she could no longer live at home. She reported physical and emotional abuse. As her mother refused to agree to her becoming looked after, the Council took emergency action to accommodate her and later secured a care order from the court.
  2. Shortly after coming into care, Ms D spent a period as an in-patient in a Child and Adolescent Mental Health Services (CAMHS) ward. The Council says once discharged, Ms D was offered specialist CAMHS Dialectical Behaviour Therapy (DBT) and trauma-focused Cognitive Behavioural Therapy (CBT). Records provided by the Council show CAMHS withdrew DBT in 2018 due to Ms D not attending appointments. Ms D told me this was because of the distance she had to travel and her poor mental health at the time.
  3. In 2018, Ms D moved to a placement offering 24-hour support. She was referred to a local CAMHS and was assigned a care coordinator. Records suggest the transfer between CAMHS in different areas took a long time and Ms D’s social worker made a complaint about this delay.
  4. In February 2019, the Council held a final looked after child review meeting for Ms D. It noted she had been encouraged to speak to a counsellor at school, but she had not made full use of the service. The Council recorded it had asked about further DBT once Ms D transferred to the local CAMHS but noted this would be considered once she transitioned to adult mental health services. When asked about her emotional health, Ms D said she thought she was “doing okay”.
  5. At the same time, the Council updated its pathway plan for Ms D. It said she would be transferred to adult mental health services and her social worker would attend the handover meeting. One of the outcomes of the plan was for Ms D to have access to the right therapeutic services. The plan noted Ms D would need to understand adult mental health services worked differently to CAMHS and she would need to be proactive about her engagement.
  6. Ms D remained open to CAMHS for some months after she left care. The Council says adult mental health services offered her therapeutic support until the end of 2019 at which point her case was closed because of non-engagement. Case notes reflect Ms D’s mental health had remained stable from June 2017 onwards.
  7. In early January 2020, Ms D reported to her personal adviser that she felt she had underlying issues with her mental health which needed addressing. The personal adviser agreed Ms D’s keyworker in her placement would follow up on this though there is no record of what action they took.
  8. Ms D’s pathway plan in October 2020 noted there had been improvements in her mental health but she still reported low mood. Her pathway plans included contact details for services that might be able to help her, and her personal adviser noted Ms D had access to local counselling services.
  9. In March 2021, Ms D told her personal adviser that she was thinking of engaging in therapy. She said her GP had advised her to refer herself for therapeutic support, but Ms D had not yet done so.
  10. At the time of writing, Ms D is transitioning towards independent living.
  11. As part of this investigation, the Council highlighted the actions it has taken to improve services. It has developed a corporate parenting strategy setting out how it will improve its services for children in care and care leavers. The Council says the strategy is discussed at service meetings and scrutinised by councillors and representatives from the children in care council.
  12. The Council has also reviewed commissioning arrangements and housing pathways for care leavers to expand the capacity to provide suitable accommodation and developed a transitions service for young people with complex needs transferring from children’s to adults’ services.

Analysis

Events in 2013

  1. In response to my enquiries the Council acknowledged the assessment it completed in 2013 was brief. It said the quality of social work intervention was not what would be expected of current practice but said the assessment needed to be considered within the context of practice standards at the time. It said with the benefit of hindsight and in the context of current practice standards, the decision to step the case down to family support services was “overly optimistic” and it believed the case would be managed differently today. However, it said the Council’s approach was sufficient in the context of social work practice in 2013.
  2. I disagree. The principles of undertaking a good assessment are broadly the same in both the 2013 version of Working Together to Safeguard Children and the current version. The assessment failed to comply with these principles, and this is fault:
    • The Council should have carried out individual assessments of Ms D and her sibling, rather than a joint assessment. The assessment did not consider the impact on them as individuals. There was no consideration of the impact of their status as young carers on their welfare.
    • There is no evidence the social worker tried to contact Ms D’s father, who she had contact with and who lived in another London borough. There is also no evidence of any requests to other agencies to contribute to the assessment until after the assessment had been completed. Although the original referral highlighted concerns from the young carers service about Ms D, there is no evidence the social worker sought a view from this service as part of the assessment or sought further information from her school.
    • There is no record of the social worker’s referral to the support service or whether the referral was accepted.
  3. It is not possible to say that a more detailed assessment would have led to a different outcome for Ms D. However, the faults identified create uncertainty about whether such an assessment would have resulted in further intervention or support and what effect this may have had on Ms D’s future well-being.

Support from the Council

  1. Records show Ms D had regular visits from her social worker and was assigned a personal adviser once she left care who also kept in regular contact with her. The Council held looked after child review meetings and reviewed her pathway plan regularly, involving Ms D and other professionals supporting her. The Council continued to fund a supported placement for her into adulthood in recognition of her mental health difficulties.
  2. The Council is not responsible for delivering therapeutic support to Ms D; this responsibility remains with local mental health services. Any concerns about the adequacy of therapeutic provision and the cost of medication would need to be directed towards the relevant NHS trusts.
  3. However, as a corporate parent the Council had a responsibility to ensure it promoted the mental health and well-being of Ms D and helped her to gain access to and make best use of services.
  4. Records show Ms D has not engaged with services at times. The Council liaised with CAMHS while Ms D was a looked after child and with adult mental health services once she left care. However, more recently Ms D has expressed an interest in seeking support for her mental health difficulties. There is no record of what action the Council has taken to help her to gain access to services. This was fault.
  5. Again, it is not possible for me to say to what extent this fault may have contributed to Ms D’s mental health difficulties. However, it does create uncertainty about whether she would have received more support if the Council had complied with its duties as a corporate parent to promote her mental health and well-being.
  6. I am satisfied the Council has taken steps to identify how it will improve the service it provides to looked after children and care leavers through its corporate parenting strategy.

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Agreed action

  1. In making these recommendations I have I have considered the Ombudsman’s Guidance on Remedies. We aim to put the person who has suffered an injustice back in the position they would have been in, but for the fault. Where that is not possible, we suggest a financial sum instead to recognise the injustice. This is not compensation. Compensation is a matter for a court and the sums awarded are on a different basis.
  2. Within one month of this decision, to remedy the injustice caused, the Council will:
    • apologise to Ms D for the inadequacies in the assessment completed in 2013 and pay her £500 to recognise the uncertainty caused by this fault.
    • apologise for the fault identified in the way the Council carried out its corporate parenting duties and pay her £100 to recognise the uncertainty caused by this fault.
    • ask Ms D what support she might need to refer herself for further therapy, and help her to access and make best use of services.

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Final decision

  1. I have completed my investigation. Ms D has been caused an injustice by the actions of the Council and it has agreed to take action to remedy this injustice.

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Investigator's decision on behalf of the Ombudsman

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