Summary: Mr B complained the Council failed to keep his daughter safe while she was known to its children’s services. We upheld the complaint noting an earlier investigation had found fault in its case management. In addition, we found fault in how the Council responded to findings resulting from that earlier investigation. As a result, Mr B suffered injustice mainly in the form of distress. The Council accepted these findings and agreed action to remedy this injustice, set out in detail at the end of this statement.

The complaint

1. I have called the complainant ‘Mr B’. He complains the Council failed to keep his daughter ‘C’ safe, while she was known to its children’s services. Also, that the Council wrongly sought to pursue allegations about his parenting instead.
2. Mr B says as a result he was scared and worried for C’s wellbeing, causing great distress. That he also felt powerless to protect her. Mr B felt his rights as C’s father were violated and he was treated unfairly.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
4. 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. If we are satisfied with an organisation’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

6. Before issuing this decision statement I considered the following:

• Mr B’s written complaint to the Ombudsman and any supporting information he provided;
• papers forming the investigation of Mr B’s complaint before he contacted this office; Mr B’s complaint went through all three stages of the procedure for investigating complaints about children’s services, described below;
• further information provided by the Council in reply to my enquiries;
• any relevant law or guidance as referred to in the text below.

7. 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.
8. I also gave Mr B and the Council a chance to comment on a draft of this decision statement. I took account of any comments they made in response before I finalised the content of this decision statement.

Back to top

What I found

Legal Background – Child Protection

9. Councils have a duty to investigate if there is reasonable cause to suspect that a child in their area is suffering, or is likely to suffer, significant harm. They must make such enquiries as considered necessary and decide whether to take any action to safeguard or promote the child’s welfare. (Children Act 1989, section 47)
10. If the information gathered under section 47 supports concerns and the child may remain at risk of significant harm the social worker will arrange an initial child protection conference (ICPC). The ICPC decides what action is needed to safeguard the child. This could include putting a child on a child protection plan (CPP). Child Protection Conferences are multi-agency bodies and are not, by themselves, bodies within the Ombudsman's jurisdiction to investigate.
11. A CPP will be reviewed at further review child protection conferences (RCPC). A RCPC can decide whether to maintain, amend or discontinue a CPP. It can also decide to ‘step down’ a case to treat a child as a ‘child in need’ (CiN) and implement a safety plan accordingly. It is the Council’s responsibility to carry out actions agreed in a CPP or CiN safety plan.
12. Where a child is on a CPP there is an expectation that a ‘core group’ meet regularly to develop and review the CPP and facilitate in-depth assessment to inform decisions about a child’s welfare. There is also an expectation that social workers visit children on a CPP regularly to check on their welfare.

Legal background – children’s services complaint procedures

13. The law sets out a three-stage procedure for councils to follow when looking at complaints about children’s social care services. The accompanying statutory guidance, ‘Getting the Best from Complaints’, explains councils’ responsibilities in more detail.
14. The first stage of the procedure is local resolution. Councils have up to 20 working days to respond.
15. If a complainant is not happy with a council’s stage one response, they can ask that it is considered at stage two. At this stage of the procedure, councils appoint an investigator and an independent person who is responsible for overseeing the investigation. The Council must then respond to the stage two report.
16. If a complainant is unhappy with the outcome of the stage two investigation, they can ask for a stage three review by an independent panel. The council must hold the panel within 30 days of the date of request, and then issue a final response within 20 days of the panel hearing.
17. If a council has investigated something under the statutory children’s complaint process, the Ombudsman would not normally re-investigate it unless we consider the investigation was flawed. However, we may look at whether a council properly considered the findings and recommendations of the independent investigation.

Chronology of Mr B’s complaint

18. Mr B first made a complaint to the Council in June 2020. He said he was concerned for C’s welfare. C was in the care of her mother ‘Ms X’. Mr B’s primary concerns focused on Ms X’s use of alcohol and her relationship with a known sex offender ‘Mr Y’ – and the impact of these factors on her parenting of C.
19. The Council replied to the complaint in July 2020. It said C’s case had been open to its children’s services since March 2018. C had been subject to a CPP between April 2018 and May 2019 and thereafter a CiN plan. The Council also said it had opened an investigation in March 2020 under Section 47 of the Children’s Act to see if C was at risk of significant harm. As a result, it had convened a further ICPC. The Council apologised it had not invited Mr B to the ICPC, although said it had sent him a copy of the assessment it carried out subsequently. The Council defended its response to specific allegations about Ms X’s behaviour and said it would consider legal proceedings if there was “no sustainable improvement” in this.
20. The Council response also noted that historically a concern had been raised about Mr B’s parenting of C; with an allegation made he had used inappropriate physical force against her. It denied that one of its social workers had acted in a discriminatory way towards him.
21. Mr B was unhappy with this response and chose to escalate his complaint to stage two of the children’s complaint procedure. He agreed a statement of complaint with an independent investigator that would consider whether Ms X had neglected C and the Council had failed to take action to safeguard her. Mr B relayed a series of incidents giving concern, where he believed the Council should have taken further action to safeguard C. These included that:

• social workers had visited Ms X when she was drunk;
• social workers were aware Ms X had been begging on the streets;
• the Council knew Ms X had been found drunk outside her home (resulting in hospital admission) but took no action;
• Ms X allowed Mr Y to collect C from school and spend time with his relatives;
• the Council was aware that C had reported being in the same bed as Ms X and Mr Y while they were having sex;
• C had been expected to care for Ms X while they were both homeless and not received support;
• C was posing as an adult on social media;
• Ms X had been frustrating or stopping contact with social workers;
• Ms X had made false accusations about him; together with his appearance this had led social workers to make negative inferences about his parenting skills.

22. The Investigating Officer produced their stage two report in October 2020. It set out a lengthy chronology of events including that in February 2018 a referral had been made alleging inappropriate physical chastisement of C by Mr B. That report was found unsubstantiated.
23. I will not set out all the remainder of that chronology in this statement, but I note the following significant incidents were recorded:

• that in March 2018 the Council received a safeguarding referral from a hospital after Ms X attended in an intoxicated state with C present;
• that a resulting investigation found Ms X was living with Mr Y’s mother. Ms X had then entered into an agreement with the Council to reside with one of her own relatives instead;
• that in March 2018 the Council had received a report from a third party that C reported sleeping in the same bed as Ms X and Mr Y while they were having sex; Mr B later made this same allegation in April 2018;
• that in April 2018 the Council had put C on a CPP because of concerns she was neglected. The CPP included measures providing support for Ms X to address alcohol and substance misuse and to provide therapeutic services for C;
• that in June 2018 the Council was aware Ms X was not attending a service to help her with alcohol misuse;
• that a July 2018 review of the CPP recorded that Ms X had been seen while drunk by her social worker and that she was in a relationship with Mr Y. The plan was reviewed to incorporate measures to keep C apart from Mr Y;
• that in August 2018 the Council had agreed to carry out a risk assessment of Mr B; it recorded him failing to attend on two occasions in October 2018 for this assessment to take place;
• that in October 2018 Ms X was reported as not co-operating with drug and alcohol support services; by November 2018 the Council had conflicting information about whether Ms X was still drinking;
• in November 2018 Ms X and C moved to a hostel; Ms X told the Council she was in a relationship with Mr Y but that he did not have contact with C;
• in January 2019 Ms X was known to be drinking again and on one occasion had failed to collect C from school;
• that in May 2019 the Council had taken C off a CPP and her case would now be subject to a CiN plan; this was because Ms X was now considered to be engaging well with services;
• in October 2019 Mr B had attended a meeting with the Council. He expressed concern Ms X was drinking again. The notes had recorded the social worker expressing concern at conflict between Mr B and Ms X;
• that in December 2019 the Council had reported more positive engagement by Ms X with services; she was then not at home when the Council carried out pre-arranged visits later that month and in January 2020;
• in January 2020 the Council received a report Mr Y would be moving in with Ms X but took no action;
• in February 2020 the social worker visited Ms X and found an unidentified male with her and she was seen trying to hide alcohol;
• in March 2020 C made an allegation of physical chastisement against Mr B. This was reported to the police who took no action. The Council began new enquiries under Section 47 of the Children’s Act;
• also in March 2020, there were two further attempted visits to Ms X where she was not at home. Ms X refused to sign a ‘working together agreement’ with the Council to stop contact with Mr Y;
• in April 2020 C’s case was referred by the ambulance service which had responded to an incident where Ms X was intoxicated; the Council notes suggested C would be cared for by extended family;
• also during that month Ms X was again not at home when visited and then later refused entry to a social worker; she also did not respond to attempts at ‘virtual contact’ during the early weeks of the pandemic. The Council completed its Section 47 enquiries;
• in May 2020 an ICPC resolved to put C back on CPP. The report identified confusion about the reasons for this. A social work manager had suggested it was because of concerns about Mr B. But the Chair of the ICPC told the Investigator it was because of the long-standing concerns about Ms X’s parenting including her alcoholism and relations with Mr Y. The CPP had set out measures including that Ms X again engage to deal with substance abuse issues and that the Council would make checks with other agencies about Mr Y. It also said Mr B was also not to have contact with C until a risk assessment had completed;
• later that month the Council was able to visit C, but Ms X then again stopped the Council visiting her. In July 2020 the Chair of the RCPC raised a ‘practice alert’ as the Council had not seen C since May and there was no social work report for the RCPC; later that month they also expressed concern the Council was not undertaking any legal planning; at the end of July 2020 the RCPC took place and the Chair expressed concern at the lack of progress in implementing the CPP and the lack of contact with C;
• in September 2020 the Council had convened a legal planning meeting and resolved to keep working with the family; the report noted there was still no evidence of progress in carrying out the steps required in the CPP; they noted no record on file of any concerns raised by Mr B for C’s social media use.

24. The Stage two findings included that:

• the Council had been right to make enquiries into C’s wellbeing in 2018 and refer her case to an ICPC; but there was no investigation of the incident where C said she witnessed Ms X having sex even though the Council knew about this from more than one source. The report highlighted that this would be form of child sexual exploitation as defined in specialist guidance. So, the Council had “failed in their duties in relation to this matter”;
• that there had been “significant drift and delay” from January 2020 onwards when new concerns were raised about Ms X’s co-operation and C’s wellbeing;
• that no safety planning for C had taken place before the ICPC in May 2020; which was also delayed;
• since May 2020, there had been a failure in ensuring the steps identified on C’s CPP were carried out. This included that there was no evidence that Ms X’s parenting capacity had been explored as part the Council’s assessments. It had not drawn up a Working Together Agreement regarding her relationship with Mr Y and not liaised with relevant drug and alcohol support agencies;
• the Council had failed to see C every 10 days and carry out direct work with her (a legal requirement for a child on a CPP); finding social workers had taken an approach “more parent-led than child-led”. The Council had therefore “failed to gain a clear understanding of C’s lived experiences and the impact of mother’s lifestyle”;
• since May 2020 the Council had failed to convene sufficient core group meetings;
• it had not carried out risk assessments of Mr B which was “significantly impacting” on him as he could not have direct contact with C. The Council also failed to keep records around its contact with him. For example, why he had not been consulted about, or invited to, the ICPC in May 2020. While the report did not criticise the meeting Mr B had with the social worker in October 2019 it found no record the concerns he raised at that meeting had been taken seriously.
• it had not referred concerns about Ms X’s relations with Mr Y to MAPPA (Multi Agency Public Protection Arrangements). These arrangements refer to the expectation that councils should work with other agencies such as police and probation services to protect the public by managing risks associated with violent or sexual offenders in the community. The Council had “placed too much reliance on the children’s mother managing these risks herself". It also noted Ms X had associations with other unknown males. The Council had not checked who these were;
• it noted an unfortunate high turnover of staff which may have impacted on the Council’s performance.

25. The Stage two report made thirteen recommendations. Some of these were specific to C’s case including:

• that the Chair of the RCPC should consider bringing the next meeting forward;
• that the Council should keep Mr B informed of legal planning meetings; that it carry out risk assessments on him as a priority; and that he be “invited and encouraged to participate in all interventions and work being planned with his daughter”.
• that C’s social worker complete an updated chronology of significant events in C’s life; it should carry out direct work with C to investigate past events including her account she had shared a bed with Ms X while she had sex; that work be done with her around her use of social media and keeping safe; that safety planning for C be undertaken “as a matter of priority” in respect of Mr Y and “any other known male associates”;
• that at least every four weeks a social work manager should review progress.

26. In terms of wider lessons, the report recommended:

• relevant staff be reminded of multi-agency protocols for when they have “reasonable cause to suspect that children are being exposed to the presence of a dangerous offender”;
• the Council should put a procedure in place to outline what action it would take if it did not see children on a CPP within statutory timescales;
• it should also ensure birth fathers are “routinely encouraged to engage in assessment process” or record reasons if they are not.

27. The Council responded to the stage two report in December 2020. It apologised for not responding sooner. The Council said it was committed to learning from the case and the findings had gone to its principal social worker, social work and quality assurance teams for action. It would also carry out a ‘learning review’. The Council accepted all the recommendations made.
28. Mr B did not consider his complaint had been taken seriously enough and so in early 2021 escalated it to stage three of the procedure. I summarise his reasons as follows:

• he did not consider the Council had taken seriously enough his concerns about C, putting undue focus on historic concerns about his actions. He continued to express frustration at the meeting he had with the Council in October 2019;
• he considered Ms X dictated the terms on which the Council had contact with C;
• he considered the Council had not responded properly to the incident in April 2020 when Ms X was found drunk;
• the Council had still not undertaken work with C around her use of social media;
• that C was often unsupervised because of Ms X’s alcoholism and would have to care for herself and would be online;
• that the Council should not have arranged the hostel accommodation as this led to a deterioration in Ms X’s behaviour with impacts on C;
• that he was excluded from much of his daughter’s life and felt the Council’s failure to take his concerns seriously contributed to this.

29. The stage three review panel met in late March and issued its findings in early April 2021. The panel was extremely critical of the Council and summarised its findings as follows: “This is a very concerning case and despite a comprehensive and detailed Stage 2 investigation, the child remains at risk and there has been a lack of management oversight, unacceptable drift and practice has been inadequate. The majority of the actions agreed in the adjudication letter [December 2020] at the time of Panel remained outstanding. Panel were dismayed that key actions and recommendations regarding the Child Protection Plan for a […] child who has spent 33% of her childhood with the involvement of Lambeth social care have not been actioned and there are no defensive or logical reasons why these have not been progressed”.
30. The panel found further failings by the Council which the stage two report had not acknowledged. These centred around the incident in April 2020 where the Council should have told Mr B of the incident, but it did not. It noted the Council had failed to check if any family could care for C at the time and did not check on her wellbeing for two days afterwards. The only part of the complaint which was not formally recorded as upheld was that concerned with the meeting between Mr B and the social worker in October 2019.
31. The panel noted that in January 2020 Ms X and C had moved to a neighbouring London authority. The findings noted further fault by the Council in not arranging a timely transfer of C’s case to that authority. But the panel also noted the Council was still considering taking legal proceedings and it was told it would retain management of the case while this consideration remained ongoing.
32. The panel noted that the Council was now undertaking direct work between Ms X and C around online safety after an “unacceptable delay” in doing so.
33. But it criticised the Council for still not undertaking work to refer Ms X’s association with Mr Y to MAPPA. The Chair of the Panel commented that after the hearing he had liaised further with the Council and still “not received reassurance or evidence that this has been actioned”. The panel’s decision explained concerns the Council had not followed its quality assurance policy to ensure it had contact with C and to escalate concerns where contact was not made. Nor that the panel saw evidence the Council was working with fathers as it had been recommended to.
34. In total the panel made a further 29 recommendations. Those specific to C’s case included:

• that it carry out an immediate risk assessment of Mr B and complete this by the end of April 2021;
• that the Council continue to manage C’s case until it had decided on potential legal action.

35. In terms of wider learning for the Council, the panel recommended:

• it keep records of the reasons for any delay in responding to complaints at stage one of the process. That it introduce a process to ensure that updates on outstanding actions arising from complaints were escalated through children’s services management if those actions remained incomplete. That it maintain better oversight of stage two recommendations to ensure delivery;
• a review of its case transfer policy, noting C had six different social workers during the events covered by the complaint;
• a review of the quality assurance alert system;
• it issue a reminders to staff and managers about the need to act on concerns raised by CPC Chairs and to escalate those concerns if they were not dealt with. Also that it issue a reminder to staff to follow pan-London child protection guidance including that on working with sex offenders and MAPPA protocols. The Chair recommended the Council carry out a “service wide audit” of cases where there were cases with known registered sex offenders to see if procedures were being followed;
• improvements to staff supervision;
• improvements to the tracking and scheduling of legal planning meetings to avoid delays;
• it issue reminders to staff on the importance of having clear and accurate chronologies on file recording significant events in a child's life to date;
• it work with practitioners to understand a number of practice issues including work with violent men; parents not engaging or hostile to the child protection procedures; ‘disguised compliance’ where parents and carers appear to co-operate with professionals and the need for professional curiosity;
• that in the absence of training on working with fathers the Council should begin routine data collection on their attendance at ICPCs and reasons for non-attendance;
• it hold a service wide learning event using the case to ensure the systematic failures regarding C’s care were not repeated.

36. The Council responded to the panel recommendations in May 2021. It said that it considered it no longer needed to carry out a risk assessment on Mr B as its most recent assessments concluded he did not pose a risk of harm to C. It also said that it could not commit to retaining oversight of C’s case moving forward, as C’s case needed to be managed by the appropriate authority in line with pan-London safeguarding procedures.
37. The response accepted many of the recommendations on how it could learn wider lessons. But it rejected the recommendation that it should review its case transfer policy saying it could not prevent social workers moving positions. It also considered a wider audit of cases involving sex offenders was unnecessary as this would only provide a snapshot in time. But it would ask relevant managers to review such cases. It also considered fathers non-attendance at ICPCs was already a matter of record. It rejected some of the suggestions for practitioner learning considering that some practices had to be reviewed on a case-by-case basis.

My investigation

38. Given that C’s case is no longer the Council’s responsibility, our investigation has sought to understand how the Council implemented the many recommendations made following investigation at stages two and three of the children’s services complaint procedures.
39. In response to my enquiries the Council sent me emails further to the stage two investigation that asked certain named officers to take forward certain recommendations. In response to the stage three investigation the Council drew up an action plan going through each of the recommendations it agreed to complete. It delegated tasks to certain roles with a completion date.
40. In checking those actions specific to C’s case which were made further to the stage two investigation, I noted the Council:

• had tasked an officer to ensure the Chair of the RCPC received the stage two investigation findings for consideration of further action; this was in early January 2021;
• had carried out legal planning meetings in early December 2020 and May 2021; the Council has a note that Mr B raised a query about the legal planning process in March 2021; it considers this indicates that he was told about what happened at the December 2020 meeting at that time. It says Mr B failed to attend a meeting in May 2021 when it would have told him about the outcome of the legal planning meeting earlier that month;
• carried out a review of C’s case by a social worker manager in early November 2020; mid-January 2021; mid-March 2021 and late August 2021;
• completed a chronology of significant events in C’s life and it shared that with me;
• had not discussed C’s account she had shared a bed with Ms X while she had sex nor discussed with C, Ms X’s association with Mr Y or other males. It said that its social workers would only have discussed these matters had C brought them up in one-to-one work which she had not done;
• had begun work with C on her use of social media in April 2021; it sent me some details of this;
• had no record of inviting Mr B to a RCPC in October 2020 but did invite him to the next meeting in early February 2021; it also met with him in March 2021 and he was given a copy of C’s CPP both at that meeting and electronically a week earlier. It sent him paperwork associated with its risk assessment at the end of March 2021.

41. The Council also told me C’s case transferred to the neighbouring London authority in early May 2022. The Council said as part of the transfer process it gave the other authority a copy of C’s CPP, CPC minutes and recent assessments of C’s needs. It also says that in September 2022 the neighbouring authority made a request to read C’s file. It believes the other authority will therefore be aware of Mr B’s complaint and the findings reached on it.
42. In terms of the service improvements recommended as a result of the stage two and stage three investigations, I noted:

• a council officer now tracks the completion of actions arising from stage two complaints and can escalate to senior officers if these are not completed;
• senior officers met in early February 2021 and began developing materials for the learning review;
• the Council subsequently gave a presentation to ‘practice leads’ within its children’s care services which summarised learning from Mr B’s complaint;
• social workers have access to a variety of materials through their ‘practice hub’. These have been updated following this complaint to include more materials on working with fathers. The Council explained the hub also provides a link to relevant pan-London child safeguarding procedures and guidance;
• the Council’s expectations of its social workers set out in its practice standards have also been updated;
• there was an additional ‘toolkit’ and handbook for new starters stressing the importance of the practice standards and materials referred to above;
• the Council also held children’s social care workshops which included sessions on the practice standards and ensuring fathers’ involvement in cases;
• that it had introduced a procedure whereby a senior officer received a weekly list of all cases where children on CPPs had not been seen in the statutory timescales; those cases could then be escalated for further action;
• it had revised its Quality Alert Procedure which is used where a Chair of a CPC has concerns about social work practice and considers the Council should take urgent action to address this. Such cases can now be escalated more quickly to senior officers for action;
• it had revised its supervision policy in March 2021;
• it had delivered training to staff on drawing up chronologies for all children in need of social work support and was monitoring the effectiveness of this through staff supervision.

43. While the Council had not given a commitment to review the child transfer policy, the action plan it produced after the panel findings said such a review was under way.

My findings

44. Between March 2018 and May 2021, a series of concerns were raised for C’s welfare and there is no dispute these justified engagement with the Council’s child protection services. Investigation of Mr B’s complaint found this service consistently let C down and led both the independent investigator at stage two of the complaint procedure and the review panel at stage three to make unusually strong criticism of the Council. I have summarised some of the most significant failings identified above. These reflect poorly on the Council and are evidence of fault in its management of C’s case.
45. I see no reason to expand significantly on those findings, arrived at after thorough investigation. I am aware that Mr B remains aggrieved at how one of the Council’s social workers spoke to him at a meeting in October 2019. Further, that he feels there is some evidence of bias against him, as the Council gave the impression of taking concerns about his behaviour far more seriously than those around Ms X. However, I consider these matters were addressed fairly in the earlier investigation of Mr B’s complaint. Like the stage two investigator I cannot come to any more definitive view of what happened in the October 2019 meeting. And where the Council received reports of Mr B’s behaviour or actions giving rise to concerns they could not ignore these. But overall, the findings of the investigation leave the reader in no doubt that Mr B was marginalised during the Council’s involvement. His voice, giving rise to a series of valid concerns about C’s wellbeing, was sometimes not considered or heard when it should have been.
46. The only area where I draw attention over and above the findings reached earlier in this case is about the transfer of C’s case to another London authority. I have checked the pan-London procedures and these say that when a child moves to another authority area the Council should alert the new authority “at the earliest opportunity”. As I understand it Ms X and C moved out of the Council’s area in early 2020 but nothing was done to alert the new authority until May 2021. That justifies a further finding of fault. I mention this issue specifically as I did not find evidence the Council had yet learnt lessons from this part of the complaint.
47. I considered next the actions taken by the Council in response to the stage two investigation, the findings and recommendations of which the Council accepted. However, I note it took the Council around two months to do so – a delay which justifies a finding of fault.
48. It is also evident the Council did not have in place an effective system for ensuring the recommended actions were carried out. Its complaint service sent emails to relevant officers but there was no form of monitoring to ensure those actions completed. As a result, Mr B and at times C, were further let down and the Council was at fault because:

• Mr B was not kept informed of legal planning meetings as the Council had promised he would be. There was four-month delay between the legal planning meeting in December 2020 taking place and there being any discussion of this with him. Although in addition, the Council’s note does not confirm Mr B learnt anything about what was discussed or decided at that meeting. So, I cannot even find at that point the Council did what it said it would;
• I accept the point Mr B missed an opportunity to learn about the subsequent legal planning meeting in May 2021 when he did not attend the Council offices later that month. But I consider the Council put too much emphasis on face-to- face contact here. I do not see why it could not write to, or telephone Mr B and give him an update;
• C’s case was not subject to regular case supervision by a manager as the Council had promised. The Council said a manager would review the case every four weeks. Yet it only carried out two such checks in the next four months and then none for a further five months;
• the Council did not explore with C, as it had agreed to do, the reported episode where she was said to have witnessed her mother having sex or talk to her to establish more about the unknown males in Ms X’s life. I accept the Council social workers may have felt to engage C in discussion about allegations or speculation could be seen as poor practice by asking leading questions of a child. But if so, the place to challenge this was in the letter sent in response to the stage two investigation report;
• there was a lengthy delay of around four months (so six months after the stage two report completed) before the Council began the agreed work with C on use of social media;
• it failed to carry out a risk assessment of Mr B as promised.

49. In addition, I considered the evidence suggested that more generally the Council continued to communicate poorly with Mr B. It is not explained why it took until March 2021 for him to receive a copy of the CPP. Nor how the Council updated Mr B if he was unable to attend CPCs.
50. Further, I am not sure the chronology the Council agreed to draw up for C was done in good time. Nor that it was the sort of document the stage two investigation had in mind. This is because it appears to be more a document that lists C’s contacts with social care services than of significant events in her life. It is also not exclusive to her as the chronology merges her experiences with those of a sibling, whose circumstances are not the subject of this complaint.
51. I ask the Council to note my findings at paragraph 49 and 50 above, but consider the evidence is insufficient to reach a further finding of fault.
52. Next, I considered how the Council responded to the stage three panel report. I did not find the recommendations given by the panel were always easy to follow. Some of them read more as findings than recommendations; or else they contained passages quoting sources for good social work practice without always making clear the reasoning behind the recommendations. But clearly the focus of the panel was on encouraging the Council to improve its social work practice to the benefit of all.
53. I considered the Council’s response to the panel findings generally satisfactory in the circumstances. I agree that it had no choice but to transfer C’s case to the neighbouring authority in line with the law and pan-London procedures. I have also listed above the many changes the Council made to the materials its social workers have access to. It has made improvements to its practice standards, delivered training and introduced new policies. I note in particular that it now has a policy to ensure it takes follow up action where it has not seen a child on a CPP in the statutory timescales and one to escalate concerns of CPC Chairs more quickly. It has also introduced what should be a more effective monitoring procedure to ensure actions agreed from stage two children’s complaints are actioned. The Council has also sought to emphasise some key messages through targeted presentations and training. All of this may provide some reassurance that the criticisms made of the Council in this case are less likely to be made in the future.
54. I noted the Council did not agree to every recommendation made by the panel. Where it did not do so, it gave reasons. I did not consider there was any fault in this, although I had two particular concerns.
55. First, in the Council’s response to the recommendation it revisit its case transfer policy. I considered the Council made a valid point that it could not stop social workers moving between posts. However, I considered this overlooked the thrust of the panel’s concerns, which were around the quality of the handover. But that said, as the Council has been reviewing this policy in any event I see no need to make any further recommendation on this point.
56. Second, I understood why the Council did not think an audit of cases appropriate to consider any other cases where there were concerns about contact between children and registered sex offenders. It suggested instead that it would give advice to managers to highlight this issue on a case-by-case basis as part of supervision; something that could have the same impact. But the Panel also wanted to see that relevant staff were reminded of existing procedures, which if followed may reduce problems in this area being picked up at supervision. I am concerned that an important recommendation from this complaint may have been lost therefore. Which was the importance of reminding staff to follow existing pan-London child protection guidance on working with sex offenders and MAPPA protocols. The Council’s assurances on this point were more general than specific.

The injustice caused to Mr B and considerations on remedy

57. I find that because of the faults summarised in paragraph 44 Mr B was caused prolonged, significant and unnecessary distress. This was as a result of the failings by the Council in taking action to safeguard his daughter and then being marginalised when he tried to raise concerns. While I consider the stage two and stage three investigations made helpful recommendations to improve case management, I do not find these fully remedied this injustice and so it is appropriate I consider recommending a financial payment for Mr B’s distress, in line with Ombudsman guidance.
58. Also, Mr B was put to unnecessary time, trouble and frustration in raising his concerns and after making his complaint. There is always a degree of time and trouble attached in asking for a service or making a complaint. But in Mr B’s case this went beyond what might be reasonably expected because the case management and response to the complaint was so poor.
59. I cannot say that this injustice extends to any estrangement Mr B has from his daughter. But I understand there will be some uncertainty for Mr B, which we also regard as a form of distress. Because he will not know how events may have transpired with different or more timely action from the Council including the case transfer to the neighbouring London Borough. Mr B considers his parental responsibility was undermined by the actions of the Council and it is understandable he has this view for the reasons set out above.
60. Mr B’s distress was further compounded by the poor response to the stage two investigation of his complaint. We consider outrage is a form of distress, and Mr B will have a legitimate feeling of outrage here. Because the unusually strong findings of the stage two investigation made clear the urgency with which the investigator expected the Council to act to improve the management of C’s case and communications with Mr B. Yet a series of agreed actions were not undertaken. C’s case management continued to drift and communications with Mr B remained sporadic at best.
61. There is also uncertainty about the extent to which the Council’s poor management of the case will have impacted on C.
62. I set out below my recommendations for how the Council can remedy Mr B’s injustice. However, I cannot make recommendations that impact on the social work management of C’s case as it is now managed by another council.
63. In considering Mr B’s distress, I have made clear that I consider this can be distinguished in several different regards. We would not usually recommend a payment of more than £300 but in a case where in effect, we find three different findings of distress arising from separable fault it is appropriate the Council provide a remedy that takes account of this multiplication. In addition, I considered the Council needed to recognise Mr B’s time and trouble.

Back to top

Agreed action

64. The Council accepts the findings set out above. It has also agreed a series of actions to remedy Mr B’s injustice and to make wider service improvements. Within 20 working days of this decision the Council will:
1. give a further apology to Mr B accepting the findings of this investigation;
2. pay Mr B £1150 in recognition of his distress, time and trouble;
3. write to the neighbouring London authority that now manages C’s case, enclosing a copy of this decision statement so that it may be linked to C's records.
65. Within three months of a decision on this complaint the Council will:
1. complete an audit based on a representative sample of recent cases where stage two investigations under the children’s complaint procedure have resulted in agreed actions; to assess whether measures to ensure such actions are carried out in a timely way are proving effective;
2. ensure that all staff receive a briefing, whether by way of an email or at team meetings or similar, stressing the importance of following the pan-London child protection guidance on working with sex offenders and MAPPA protocols – a key learning point from this complaint. That briefing should also remind staff of their responsibilities to transfer cases to other authorities, where a child moves out of area while their case remains open to the Council;
3. write to us having reviewed its current procedures for keeping in touch with parents whose children are subject to CPPs but with whom the child does not live and let us know if it proposes or has made any changes to these further to that review. I make this recommendation because not only should the Council record that it has sought their views and invited them as appropriate to CPC meetings and shared paperwork as required; but also consider other ways of keeping in touch such as through emails and telephone calls. There can be no ‘one size fits all’ approach to such communication which will require case-by-case consideration. But the Council should ensure that its staff are encouraged to go beyond basic requirements in ensuring communication is maintained with parents in that position.

Back to top

Investigator's decision on behalf of the Ombudsman