Summary: Ms X complains about the Council’s decision to go to Initial Child Protection Conference and place her child on a child protection plan following the sharing of incorrect information. Ms X complains this led to the Council wrongly placing her child on a child protection plan and caused significant distress. The Ombudsman finds fault with the Council for failing to suitably include Ms X in the ICPC process and for failing to suitably consider and address her concerns about incorrect information. The Ombudsman also finds fault with the Council for not suitably considering the impact on Ms X and Child A. The Council has agreed to provide a financial remedy and service improvements.

The complaint

1. Ms X complains the Council held an Initial Child Protection Conference about her son and concerns for her previous relationship, despite her telling the Council that this relationship had ended.
2. Ms X complains the Council’s decision to hold an ICPC was based on assumption, and the decision was made before the child and family assessment had been fully carried out.
3. Ms X complains the Council’s decision to hold an ICPC has severely impacted herself and her son, and the stress could have been avoided if the Council had considered the correct information beforehand.

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The Ombudsman’s role and powers

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 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)
5. 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)
6. We investigate complaints about councils and certain other bodies. We cannot investigate the actions of bodies such as Children’s Safeguarding Partnerships. (Local Government Act 1974, sections 25 and 34A, as amended)
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)

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How I considered this complaint

8. I considered Ms X’s complaint and the information she provided. I have also considered information provided by the Council. I considered comments from Ms X and the Council on a draft of my decision.
9. 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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What I found

Relevant Law, Guidance and Policy

The Children Act 1989

10. Section 47 of the Act places a duty on local authorities to make enquiries if they have reasonable cause to suspect that a child who lives in their area is suffering, or is likely to suffer, significant harm. Authorities shall make, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.

The Statutory Guidance ‘Working Together to Safeguard Children’

11. The Guidance says if a council receives a report of concern about a child, the referrer must have the opportunity to discuss their concerns with a qualified social worker. The council must then, within one working day, decide what response is required. This includes deciding whether:
12. The child needs immediate protection.
13. The child is in need and should be assessed under section 17 of the Children Act 1989.
14. There is reasonable cause to suspect the child is suffering, or likely to suffer, significant harm.
15. Where a council 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 of the Children Act 1989 to hold a strategy discussion and make further enquiries. These are to decide whether it needs to take any action to safeguard or promote the child’s welfare. Both parents and the child will normally be interviewed as part of the process.
16. If concerns of significant harm are substantiated following section 47 enquiries, an initial child protection conference (ICPC) should be arranged within 15 working days of the original strategy discussion. This is a multi-disciplinary meeting whose attendees decide what action is needed to safeguard the child. The ICPC 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.
17. After the ICPC, if the decision is to place a child under a child protection plan, there will be core group meetings with the professionals and family to assess progress. There should also be review child protection conferences (RCPC). These consider the progress taken to safeguard the child and whether the child protection plan should be maintained, amended, or discontinued.

What happened

18. In October 2020, the Council received a referral where concerns were raised about Ms X’s child, Child A and Ms X’s personal relationship with Mr Y.
19. The Council decided to investigate and carried out an assessment of the risks Mr Y posed to Child A. This included carrying out a section 47 enquiry to gather information.
20. The assessment contained information about Mr Y and Ms X’s current circumstances, and information collected from the section 47 enquiry.
21. The Council decided to call an initial child protection conference to decide whether to place Child A on a child protection plan. The Council presented the information from the assessment, the section 47 enquiry and information from other professionals.
22. At the ICPC, Ms A raised that the information in the assessment was wrong and should not have been shared with the ICPC. She also raised that information from other professionals was incorrect. Ms X also raised concerns that the Council had not shared the information with her and that it had excluded her from the assessment.
23. The result of the ICPC was that Child A should be placed on a child protection plan. One of the actions of the plan was the Council would double check the information that was presented at the ICPC.

Complaints process

24. Ms A complained to the Council in November 2020. She complained the Council had called the ICPC and placed her child on a child protection plan based on false information. She also complained about how the Council had communicated with her and included her in the assessment.
25. In the Stage 1 response, the Council said it partially upheld Ms X’s complaint. It recognised that it should have met with Ms X and better communicated with her about the concerns before the ICPC. It did not uphold Ms X’s complaint that Child A was placed on a child protection plan due to wrong information.
26. Ms A remained unhappy with the Council’s response and escalated her complaint to stage 2.
27. In the stage two response, the Council accepted that it had included incorrect information in the assessment and this was presented at the ICPC. It recognised that a social worker should have visited Ms X to discuss the concerns and gone through the assessment with Ms X before the ICPC. I am of the view this would have been the opportunity to discuss wrong information. Ms X could raise concerns at the conference, but by that time the conference had already been convened.
28. The Council also upheld that incorrect information from other professionals was shared at the conference. However, the Council did not feel this significantly impacted the professional decision to place Child A on a child protection plan.
29. The Council also upheld that it had not suitably communicated with Ms X about the concerns for her child and had not accommodated her requests for a face to face meeting. It apologised for leaving her feeling left out of the assessment and unable to voice her concerns or accurately portray her circumstances.
30. The Council upheld Ms X’s complaint and set out the following recommendations

• To improve parental engagement, the Assessment Team will review how it obtains and records the parent(s) preference of communication methods. In the event of any expression of dissatisfaction with current communication methods, the team should discuss this with the parent(s) and record any discussions and agreed outcomes.
• Staff will be provided with refresher training highlighting the importance of appropriate and timely interaction with parents during the assessment process, the importance of reviewing the assessment together and ensuring the parent(s) view of the assessment is obtained.
• The Assessment Team will look at whether improvements can be made to ensure that any missed face to face visits with families are flagged to the relevant managers.
• Both the Assessment Team and the Conference Service are to consider what action could be taken in the event that the validity of information shared at the conference is questioned.

31. Ms X remained unhappy with the Council’s response. She complained to the local safeguarding board and the Ombudsman. The Council then agreed to carry out a review of the stage 2 response. The service director met with Ms X and completed an additional investigation.
32. In the additional investigation, the Council said that for Ms X, where incorrect information was shared, the Council should have recalled the ICPC and reviewed the recommendations made at the ICPC. This would have given professionals the opportunity to make the decision based on the correct information. The Council accepted it was at fault for not doing this and said this would be the practice going forward.
33. The Council agreed to;

• Restrict the family file so only members of Senior management can unlock the file should a further referral be received. This would prevent the previous incorrect information being shared again.
• To write a management oversight on the file to ensure it is understood that should any new referral be received the Council would need to consider it within the current context and not the past based on concerns regarding previous management of case.
• For the Council to discuss the outcome of the investigation with Child A’s school.

Analysis

34. Ms X’s complaint centres around the information that was bought to the ICPC and shared by the Council and professionals. Ms X feels strongly that this led to the decision to place her child on a child protection plan.
35. I have considered the information shared at the ICPC and the reasoning for placing Child A on the register. I have also considered the Council’s response during the complaints process.
36. I have reviewed the recommendations from the stage 2 complaint, where Ms X’s complaint was mostly upheld, except for whether to call an ICPC would have changed. The Council accepted that it should have met with Ms X and clarified information before the ICPC. It also accepted it had not suitably communicated with her or included her in the assessment. This was fault by the Council causing Ms X injustice.
37. In the review of the stage 2 response, the Council set out that it was not possible to say whether the ICPC would have happened if the wrong information had been identified.
38. The Council set out recommendations for changes it would make to its own services to avoid future mistakes. However, it is my view the Council’s response did little to address the distress caused to Ms X by the Council's maladministration.
39. The additional investigation found that for Ms X, where incorrect information was shared, the Council should have recalled the ICPC and reviewed the recommendations made at the ICPC. This would have given professionals the opportunity to make the decision based on the correct information. The Council accepted it was at fault for not doing this, and said this would be the practice going forward.
40. I agree with the Council’s rationale for this action. I cannot say whether the ICPC outcome would have been different, but I agree professionals should have been given the opportunity to make the decision based on correct information. I also agree with the Council’s finding that Ms X should have been given the opportunity to discuss her concerns before the ICPC.
41. The further investigation also identified that further work should have been completed after the strategy meeting to inform what was written in the assessment. This in turn would have informed the decision whether to call the ICPC.
42. The Council agreed to;

• Restrict the family file so that only members of Senior management can unlock the file should a further referral be received. This would prevent the previous incorrect information being shared again.
• To write a management oversight on the file to ensure it is understood that should any new referral be received the Council would need to consider it within the current context and not the past based on concerns regarding previous management of case.
• For the Council to discuss the outcome of the investigation with Child A’s school.

43. Having reviewed the Council’s response to the further investigation, I am of the view the recommendations made better reflect the full extent of the fault and maladministration caused by the Council. I am of the view the Council missed these recommendations in the stage 2 response and it should have identified these earlier. It should not have needed further intervention from Ms X and investigation by the Council. This was fault by the Council causing Ms X further distress and delay.
44. I remain of the view the Council has still not addressed the impact that it’s maladministration has had on Ms X and Child A. This was fault by the Council and has caused further delay in the Council resolving the issue.
45. Ms X has been clear with the Council how stressful she has found this and the impact it has had on her and her child’s wellbeing. She has said she has worried about them as a family and whether she would lose her child because of the Council’s maladministration. She also had to pursue the complaint through the Ombudsman and the Safeguarding board to achieve suitable outcomes for her case. I consider this to have caused further distress to her.
46. By having to complete another investigations after the complaints procedure, the Council has delayed addressing the issue and establishing the suitable recommendations. The Council has also failed to provide a suitable remedy to Ms X and Child A for the distress and delay caused.

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Recommended/ agreed action

47. Within 12 weeks of my decision the Council has agreed to

• Share this decision and the outcomes of the further investigation with staff and highlight where lessons can be learnt.
• Review how it considers injustice and impact where complaints are upheld.
• Review how the outcomes of the further investigation could have been achieved at stage 2 and why they were not identified at the time.

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Final decision

48. I have now completed my investigation. I find fault with the Council for failing to suitably include Ms X in the ICPC process. I also find fault with the Council for failing to suitably consider and address her subsequent concerns about incorrect information. I also find fault with the Council for not suitably considering the impact on Ms X and Child A.

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Investigator's decision on behalf of the Ombudsman