Summary: The Council has recognised that there were faults in its child protection procedures when deciding whether to place the complainant’s son on a child protection plan. We have recommended a way to remedy the injustice caused which the Council has accepted. We are therefore closing the complaint.

The complaint

1. The complainant, who I refer to as Mrs X, complained that the child protection process was not conducted properly and that the Initial Child Protection Conference (ICPC) dealing with concerns about her son, Y, should not have taken place.
2. Mrs X says that the Council’s faults have caused the complainant and her family avoidable and significant distress when they were also dealing with the upset at seeing their son, Y, suffering from a serious mental health illness.
3. Mrs X says that she has also suffered from avoidable anxiety and suffered embarrassment and reputational damage, and financial costs in securing professional advice and support.

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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.
5. 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 future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended).
6. The Ombudsman cannot investigate whether social workers are meeting their professional standards of conduct. Complaints of this nature should be referred to the social workers’ professional body, Social Work England.
7. We normally expect someone to refer the matter to the Information Commissioner if they have a complaint about data protection. However, we may decide to investigate if we think there are good reasons. (Local Government Act 1974, section 24A(6), as amended)
8. 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)
9. 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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What I have and have not investigated

10. The Council investigated Mrs X’s complaints under its two stage corporate complaints procedure and in mid-2023 upheld or partly upheld some of her complaints. The Council’s stage 2 also upheld or partially upheld some of the complaints.
11. The main specific complaints were that:
1. the required Children and Family (C&F) assessment of the parents and their son, Y, was not completed on time before the Initial Child Protection Conference (ICPC) of early 2023;
2. the social worker did not visit Y sufficiently during the child protection process;
3. the team leader signed off the above assessment hastily. Subsequently the Council added that her oversight of the C&F assessment was not robust enough;
4. that the ‘wrong’ C&F assessment was presented to the ICPC, and it was inappropriate to provide the updated information at the conference;
5. that it was inappropriate to include the parents’ other son as part of the ICPC;
6. the social worker should have discussed the hospital’s wish to discharge Y with the parents;
7. the manager did not have sufficient oversight, that social worker should have seen Y more in his father’s care;

h) the social worker was not fully aware of the requirements of aftercare under the Mental Health Act (s117), to which Y was entitled to on discharge from hospital; and

8. there was a delay in arranging the reconvened ICPC.

12. I am not reinvestigating these complaints because there has been a full investigation by the Council both under the Council’s complaint procedures and through the multi-agency appeal against the decision of the ICPC. Overall, the complaints have been upheld. But I have considered whether the Council has fully recognised the injustice caused by these failings, and whether there has been a sufficient remedy.

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How I considered the complaint

13. I made enquiries of the Council and spoke to Mrs X on the telephone. I issued a draft decision statement to Mrs X and to the Council. I have taken into account any further comments before reaching my final decision.

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What I found

Child Protection

14. 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 decide whether they should take any action to safeguard or promote the child’s welfare. (Children Act 1989, section 47)

1.1.2 Duty to make enquiries

15. Under section 47 of the Children Act 1989, where a council has reasonable cause to suspect that a child in their area is suffering or is likely to suffer significant harm, it has a duty to make such enquiries as it considers necessary to decide whether to take any action to safeguard or promote the child’s welfare. Such enquiries should be initiated where there are concerns about abuse or neglect.
16. Councils should act decisively to protect children from abuse and neglect including starting care proceedings where existing interventions are insufficient.

1.1.3 Acting on a referral and Section 47 requirements

17. 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 that the child is suffering significant harm or is likely to do so.
18. The council should make initial enquiries of agencies involved with the child and family, for example, health visitor, GP, schools and nurseries. The information gathering at this stage enables the 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; or
• a decision to convene a strategy meeting.

19. Section 47 of the Act places a duty on agencies, but mainly the 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”.
20. 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 might include making the child a ‘child in need’ (CiN) under section 17 of The Children Act and implementing a safety plan.

Mental Health Act (MHA) 1983 and section 117 aftercare

21. Children and young people can be sectioned and detained in an adolescent psychiatric unit under section 3 for their own safety and for treatment.
22. Anyone who may have a need for community care services is entitled to a social care assessment when they are discharged from hospital to establish what services they might need. Section 117 of the Mental Health Act imposes a duty on health and social services to meet the health/social care needs arising from or related to the person’s mental disorder for patients who have been detained under section 3.
23. Section 117 aftercare services must:

• meet a need arising from or related to the mental disorder for which the person was detained; and
• have the purpose of reducing the risk of the person’s mental condition worsening and the person returning to hospital for treatment for the mental disorder.

24. The MHA 1983: Code of Practice (the Code) is statutory guidance. This means that councils and Integrated Care Boards (ICBs) must follow it, unless there are good reasons not to.

Key facts

25. This is a brief account of events.
26. Y started to have serious mental health problems. He was subsequently detained under section 3 of the MHA for his own safety and for treatment.
27. In early 2023, the Council held a strategy meeting. At this stage, Y was subject to section 3. The strategy meeting agreed that Y was at continuing risk of significant harm to himself and to others. It was agreed that there would be a s47 investigation with the aim of developing a clear plan to support the parents.
28. A social worker completed a section 47 C&F assessment. This led to the Council arranging an ICPC. This initial conference decided that Y should be made the subject of a child protection plan.
29. The parents appealed this decision. Under the complaint arrangements for such appeals, a multi-agency Panel upheld the parents’ appeal, namely that:

• the child protection processes were not followed properly;
• C&F reports were not shared on time;
• information shared was not sufficiently comprehensive and balanced; and
• the threshold for significant harm was not met.

30. The Panel asked for there to be a reconvened ICPC because the Panel was not able to overturn the original decision. A reconvened ICPC was held in mid-2023 and overturn the original decision.

Findings

31. The Council has confirmed that there were faults in the C&F assessment, an ICPC should never have been held, and Y should never have been made the subject of a child protection plan.
32. I endorse the Council’s overall findings on this complaint. I am also satisfied that Mrs X and her family have suffered avoidable distress at a time when they were already struggling with the decline of Y’s mental health.
33. To the Council’s credit, it has recognised that its actions has caused upset and it was willing to consider the suggestions we had to remedy the injustice to the family.

Mrs X’s remedy requests

34. Mrs X would like:

• an acknowledgement of the avoidable distress caused and a symbolic payment to recognize this;
• deletion of records regarding the child protection involvement. I have explained we could not achieve this. Mrs X would accept the previous file being archived;
• confirmation that training has taken place as recommended.

The Council’s response

35. As a result of this complaint, the Council says that the following actions have been taken:

• the procedure for the sharing of reports for all child protection conferences so that a conference will now be stepped down if the report has not been written, authorised and shared with parents at least two working days in advance of the scheduled meeting;
• developed a mandatory social work curriculum and practice in relation to s.47 activity and child protection conferences;
• a senior officer for safeguarding and learning has visited each of the Children’s Services locality areas to carry our training about preparing for a child protection conference;
• the specific practice issues with the team leader’s oversight and sign off of the child and family assessment were directly addressed with them, in reflective conversations and supervision;
• similarly the issues relating to the upheld complaint and findings of this were addressed individually with the social worker. The parents met the independent chair of the appeal Panel to explore and discuss the outcome of the appeal and learning from this; 
• the Council completed an audit activity in relation to strategy discussions and section 47 activity as a reassurance exercise to ensure that threshold for decision making to proceed to ICPC were right;
• all the team leaders for social work team have attended training on strategy meetings and the processes which should be followed in line with Working Together to Safeguard Children guidance and the Council’s agreed policy;
• in addition, training is being arranged for all senior practitioners who organise or chair strategy meetings which will take place by the end of March;
• officers from social work teams, in partnership with health colleagues, will complete training by end of March regarding section 117 aftercare for complex cases;
• whilst it is not possible to archive the child's case record, the Council has ensured that the record is restricted to only those working directly with the family so that other professionals cannot access the record without permission. The Council have made clear to the parents that the previous records regarding the child protection conference would not come up on any Disclosure and Barring Service (DBS) checks made on them so should not affect their employment; and
• a manager's decision has been recorded on the case record setting out what happened with regard to the child protection process and the upheld appeal, so there is a clear record for future reference. 

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Agreed action

36. We have published guidance to explain how we recommend remedies for people who have suffered injustice as a result of fault by a council. Our primary aim is to put people back in the position they would have been in if the fault by the council had not occurred.
37. When this is not possible, we may recommend the council makes a symbolic payment. Where that takes the form of a payment, it is often a modest amount whose value is intended to be largely symbolic rather than purely financial. We also support organisational learning and improvements to help others.
38. We expect senior officers from councils to make effective, timely and specific apologies for the faults we have identified.
39. In respect of symbolic payments, we take account of the severity of the distress, the length of time involved, the number of people affected and their vulnerability. We usually recommend up to £500 but we can recommend more.
40. In this case, I have done so because of the severity of the avoidable distress caused at a time when most parents would be struggling in dealing with their child’s serious mental health decline.
41. Regarding the case files, we cannot recommend deletion of previous child protection records and the Council has explained why it cannot either. I consider that the Council’s solution is appropriate. But Mrs X could take the matter to the Information Commissioner.
42. I recognise that Mrs X sought advice and support. We may recommend a contribution to costs if a complainant has engaged help, where a matter is particularly complicated. I recognise that going through child protections proceedings unnecessarily, and its implications, might mean that a parent may need to seek professional advice to limit any perceived damage to their reputation.
43. In respect of the counselling costs, it would be difficult to conclude that these arouse solely as a result of the Council’s actions.
44. Within one month of the final statement, the Council will:
1. make a symbolic payment of £1000 to Mrs X to recognize the significant avoidable distress;
2. Mrs X has not provided details of the professional advice she sought or the costs of this. It will be for the Council to determine whether it should make a contribution or pay the costs in full. This will be at the discretion of the Council, subject to Mrs X providing appropriate invoices; and
3. in respect of service improvements, the Council has learned from this complaint and implemented changes to its social work procedures. So, it is not necessary to make any recommendations.
45. The Council should provide us with evidence it has complied with the above actions.

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Final decision

46. The Council has recognised its faults causing injustice to Mrs X. It has also agreed the recommended actions. I am therefore closing the complaint.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman