Summary: We found fault on Mrs D’s complaint about the Council delaying its child protection investigation of her daughter. It delayed chasing the GP about a paediatrician’s referral and a health chronology. The agreed action remedies the injustice caused. There was no fault on her complaints of it failing to consider all the issues or not supporting her.

The complaint

1. Mrs D complains about the Council:
1. carrying out an unnecessary child protection investigation of her daughter without following the correct procedures;
2. taking more than three months to conclude it;
3. failing to consider all issues raised; and
4. not supporting her properly.
2. As a result, she and her family were placed under great stress, caused anxiety over a period of a year, all of which impacted negatively on her daughter who missed six months of school.

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The Ombudsman’s role and powers

3. 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)
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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. 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)
6. 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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Child protection law and procedure

7. The Children Act 1989 (the Act) requires local authorities to investigate if there is reasonable cause to suspect a child in their area is suffering, or likely to suffer, significant harm. They must decide whether to take action to safeguard or promote the child’s welfare. (Children Act 1989, section 47)
8. Anyone who has concerns about a child’s welfare should make a referral to children’s social care and should do so immediately if there is a concern the child is suffering significant harm or is likely to do so.
9. A council should make initial enquiries of agencies involved with the child and family, for example, the health visitor, GP, schools, and nurseries. The information gathering enables a council to assess the nature and level of any harm the child may be facing. The assessment may result in:

• no further action;
• a decision to carry out a more detailed assessment of the child’s needs (which the Council calls ‘a child and family assessment’); or
• a decision to convene a strategy meeting.

10. Section 47 of the Act places a duty on agencies, but mainly a council and the police, to make, “such enquiries as they consider necessary to enable them to decide whether to take action to safeguard or promote the welfare of a child in their area”.
11. If, following a referral and an assessment by a social worker, a multi-agency Strategy Discussion decides the concerns are supported, and the child is likely to suffer significant harm, the council convenes an Initial Child Protection Conference (ICPC). The ICPC decides what action is needed to safeguard the child. This might include making the child a ‘child in need’ (CIN) and implementing a Child Protection Plan.
12. After the ICPC, there will be one or more Review Child Protection Conferences to consider progress on action taken to safeguard the child and whether the Child Protection Plan should be maintained, amended, or discontinued.
13. ‘Working Together to Safeguard Children (2018)’ is government guidance. It says the assessment should be child-centred, focusing on the action and outcomes for children and hearing their voice, where appropriate. It should involve the family and identify strengths and protective factors as well as risks to the safety and welfare of the children.
14. It goes on to say:

• social workers should lead assessments and carry out enquiries in a way which minimises distress for the child and family. The social worker may interview the child’s parents and gather information about the child and their family history to determine the level of risk the child is likely to face if they remain in their environment.
• Assessments should take no longer than 45 days from the date of the referral.

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What I have and have not investigated

15. Mrs D complained to us in May 2023 which means we would normally investigate the Council’s actions only as far back as May 2022. I exercised discretion to investigate events from the start of the Council’s own investigation which I understand started in June 2021. I have done this because of the pressure she and her family were under and her personal circumstances.

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How I considered this complaint

16. I considered all the information Mrs D sent, the notes I made of our telephone conversation, and the Council’s response to my enquiries. I sent a copy of my draft decision to Mrs D and the Council. I considered their responses.

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What I found

17. Mrs D complains about the child protection investigation the Council carried out of her daughter, E. She claims it was unnecessary and took too long. She also complains that had the Council followed the correct child protection procedures, they would have been spared the 12 months of investigation.

Key dates:

2021:

18. 18 June: The Council received a referral from a paediatric registrar. This highlighted concerns that E’s problems were more complex than just her own psychological health needs. They felt an overall assessment of the family environment was needed. The concern was about Mrs D having Fabricated and Induced Illness (FII). This is a rare form of child abuse where a parent, for example, exaggerates or deliberately causes symptoms of illness and tries to convince doctors the child is ill, or the condition is worse than it really is.
19. Following a home visit at the end of the month, the Council had concerns about E.
20. 7 July: There was a Strategy Discussion. Its aim was for professionals to decide if E was at risk of significant harm or likely to suffer harm. Health, the police, Education, and Children’s Social Care attended. While parents are not invited to this type of meeting, it is good practice to tell them about it and the outcome, which the Council did. The meeting decided further work/enquiries were needed which would include an assessment (section 47 enquiries).
21. 8 July: The assessment worker spoke to E’s father.
22. 22 July: The assessment worker spoke to E’s father and to Mrs D who was told the Council would suspend /section 47 enquiries until there was a view from the paediatrician.
23. 8 September: The single assessment was completed.
24. 15 September: There was a further Strategy Discussion. The assessor said she had completed an assessment which found inconsistencies from a variety of professionals about the conditions Mrs D says E had. She wanted to see if the postponed meeting with E could be re-arranged. The report noted the GP had said they were making a referral to ‘paediatricians’. The meeting decided the case should go to the ICPC. Mrs D and E’s father were told of the decision the following day.
25. 20 September: An assessment worker contacted a paediatrician, and the background of concerns were shared. The paediatrician considered this required a multi-disciplinary approach as there were lots of issues. He would discuss the case with colleagues and get back to her. Three days later he confirmed he wished to assess whether E was a sick child or not.
26. 6 October: The ICPC was held which agreed E had suffered significant harm as a result of Mrs D’s responses to medical issues. A Child Protection plan was to be put in place. It decided E needed a full health review by a paediatrician. It also decided to restart section 47 enquiries. I have seen a copy of an email Mrs D’s representative sent for the ICPC to consider. This contained her comments on the information contained in the assessment.
27. 13 October: The paediatrician confirmed there could be a range of mental health symptoms/concerns which appeared to have a significant impact on E. He recommended an appointment with a mental health colleague. He also recommended a further appointment with him for any concerns not raised and for a physical examination.
28. 19 October: The Core Group met. Its role was to develop the outline plan made at the ICPC so it becomes a full Child Protection Plan which would include day to day actions and details. It noted E had a further assessment with a paediatrician the following day. It decided there was a need for a specialist psychiatric assessment of Mrs D for FII and a separate assessment of E’s father’s ability to protect her.
29. 20 October: The paediatrician confirmed E was in good health but recommended her for assessment for mental health issues and made a referral to CAMHS (the Child and Adolescent Mental Health Service).
30. 19 November: The Core Group met with Mrs D, E, and her father. It noted the psychological assessment of Mrs D.
31. 1 December: The social worker spoke to E before the review child protection conference.
32. 6 December: No referral yet was made for a family support worker for the family and nor was there funding yet for Mrs D’s psychiatric assessment. E was on CAMHS waiting list and work for her father had still to be done.
33. 14 December: A cardiac specialist found no health concerns.
34. 15 December: A Review Child Protection Case Conference decided the Child Protection Plan would continue as professionals were very concerned about E.

2022:

35. 18 February: The Council gave instructions for a psychological assessment of Mrs D.
36. 8 March: The Council chased the GP for a chronology of events which should have been completed by 30 November 2021.
37. 5 April: Psychological assessment of Mrs D completed.
38. 7 April: Psychological assessment of E’s father completed.
39. 9 May: The review conference work’s report was completed.
40. I now look at Mrs D’s individual complaints:

The complainant’s concerns

41. Mrs D complains the decision to start a child protection enquiry was premature and made without the full understanding or information about the family’s medical issues. When it started the investigation, she claims procedures were not followed, no paediatrician referral was made, and it held a child protection conference before consulting a paediatrician. Had it consulted a paediatrician earlier, she believes its investigation would not have been necessary.
42. She also believes the social worker was biased and decided Mrs D was a risky parent. She claims the social worker failed to raise professional concerns with the paediatrician, so these were not addressed. Important information from the paediatrician was not made available to the first Review Child Protection Conference. Nor was this information considered when a decision was made to continue with the Child Protection Plan. Mrs D also believes the Council failed to give her support or properly consider all the issues.
43. The Council explained the GP sought advice from a paediatrician at the time of the initial Strategy Discussion, as had the social worker. Due to concerns remaining about E, and her being at risk of significant harm, section 47 enquiries were started. This led to the holding of the ICPC which decided there was enough information about a present risk of harm to have a Child Protection Plan while further assessments were done.
44. While it delayed holding a follow up Strategy Discussion, this could not continue. When it was held, it decided E was at risk of significant harm. The Council considers it unlikely it would have ended its involvement sooner had the paediatrician’s assessment been received earlier.
45. The Council explained it had a duty to assess and explore concerns raised about the safety of E. These concerns were held by health service professionals, as well as others who took part in the Strategy Discussion.
46. It noted concerns were shared with Mrs D, she received a copy of the single assessment, child protection conference minutes, child protection plans, and all Core Group minutes. She also attended the ICPC and all reviews.
47. The Council said a social worker was supportive and understanding with Mrs D but it could not speak to another who no longer works for it. It also pointed out both Mrs D and E had advocates throughout.

My findings

48. I make the following findings on this complaint:
1. It was not premature for the Council to start its investigation when the referral was received. The purpose of starting this process was for it to gather enough information to assess whether E was at risk. It had to follow the statutory process as it would not have all the information it needed to make this assessment at this point. The decision was a multi-agency decision. It was not fault, therefore, for the Council to start the investigation based on the information it had at that time.
2. The Council said the GP asked for an appointment with paediatricians before the initial Strategy Discussion was held in July 2021. There is a reference to this in the notes of the initial Strategy Discussion. In July, the Council told Mrs D it was suspending section 47 inquiries until there was a clear view from the paediatrician.
3. There is no evidence showing when the GP made this referral or to whom. Nor is there evidence of the Council approaching a paediatrician itself before September or chasing the GP about it. The assessment was finally received in October. While this was a delay of about three months, I consider the overall delay caused was about two months. This is because it would have taken time for the Council to receive a response itself either from the GP or paediatrician. These failures amount to fault. I consider this caused some injustice to Mrs D as she has the uncertainty of not knowing if the investigation might have ended sooner but for this delay.
4. I found no evidence of bias as claimed by Mrs D. The records show legitimate concerns were raised by the health service which needed investigating. I am satisfied decisions were made based on the evidence available.
5. The Council had 45 working days to complete the assessment. The evidence shows this was due to be completed on 1 September but was finally completed on 8 September, seven days later. While the deadline was missed, I am not satisfied this caused Mrs D a significant injustice.
6. There was some delay chasing the GP for the health chronology that should have been provided by the end of November 2021. The Council only chased the GP about it in March 2022, four months later. I note the Council gave instructions for the psychological assessments in February, which must mean the funding was approved by that point. The assessments were only completed in April, the month after the Council chased the GP. I am satisfied while the overall delay was from November 2021 to March 2022, the instructions for these assessments were only given in February and it would have taken some time to arrange for them to be done, for them to be done, and passed to the Council. On balance, I consider the total delay by this failure was about a month.
7. I consider this fault caused Mrs D an injustice. This is because she has the uncertainty of not knowing whether this delayed the psychological assessments of Mrs D and E’s father. It would also have added to the stress and frustration caused.
8. I am satisfied the evidence shows the Council contacted E’s father from the start of the proceedings who was involved in meetings, for example. I have also seen records of the contact made with him in July 2021 on separate occasions and note he was psychologically assessed which took some time to do by the health service.
9. Having considered all the evidence, I am satisfied there were no other delays in the process. While there were complications, such as getting funding agreed for Mrs D’s psychological assessment, and for this to take place, I am not satisfied this was the Council’s fault. I have also taken account of the fact that following the paediatrician’s assessments, there was a recommendation to psychologically assess Mrs D, E, and her father. I am not persuaded, therefore, by her argument the child protection investigation would have not progressed further had the Council obtained the paediatrician’s assessments earlier, because there was further investigatory work to be done.
10. I found no evidence to support Mrs D’s complaint information from the health service was ignored, or the social worker misrepresented a conversation between the GP and paediatrician. All evidence was considered by the ICPC, a multi-agency group.
11. Although one social worker could not be contacted, the evidence I have seen satisfies me there was no fault on her complaint about the Council not giving her support throughout the process. In terms of her own psychological needs, the Council only became aware of these after the psychological assessment was completed, a month before it closed its investigation.

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Agreed action

49. I considered our guidance on remedies.
50. The Council agreed to carry out the following actions within 4 weeks of the final decision on this complaint:
1. Send Mrs D and E a written apology for the failure to: approach either the GP or a paediatrician sooner than it did; contact the GP sooner when the requested health chronology was four months overdue.
2. Pay £150 to Mrs D for the distress the fault caused.
3. Review procedures to ensure there are systems in place for identifying and pursuing overdue inquiries and actions by health officials.
4. Remind officers of the need to pursue health officials about referrals and health related inquiries so there are no delays on child protection investigations.
51. The Council should provide us with evidence it has complied with the above actions.

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Final decision

52. On Mrs D’s complaint against the Council, I found the following:

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Investigator's decision on behalf of the Ombudsman