The Investigation

The complaint

1. Miss X complained about the way the Council intervened after her child was born prematurely. Specifically, she complained:

• the Council wrongly put both of her children on child protection plans;

• the legal threshold to consider care proceedings was not met;

• the Council wrongly claimed she had mental health issues, and used this incorrect information in its assessments;

• the Council wrongly claimed her children’s father was abusive, and used this incorrect information in its assessments;

• the Council communicated poorly with her and with other agencies; and

• the Council excessively and disproportionately intervened.

2. Miss X said this caused unnecessary and avoidable significant distress and frustration. She said the Council’s actions traumatised her, left her scarred, and caused significant distress. She said the experience significantly impacted her mental health. Miss X said she felt shamed, misjudged and bullied. She said she was treated like a danger to her children during one of the most frightening, exhausting and vulnerable times of her life. Miss X said she and her children carry the emotional consequences every day. She said it had a significant impact on her other child. She also said it had a financial impact.

Legal and administrative background

The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this report, we 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. We 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)

4. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).

Relevant law and guidance Child protection

5. 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)

6. 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.

7. 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.

8. If the information supports the concerns, and the child may remain at risk of significant harm, the social worker will arrange a multi-agency initial child protection conference. The initial child protection conference decides what action is needed to safeguard the child. This may include a recommendation that the child should be supported by a child protection plan.

Care proceedings

9. The public law outline process takes place when a council is concerned about a child’s wellbeing. Unless positive steps are taken to address and alleviate those concerns, the council may consider making an application to court. The public law outline process is therefore the last opportunity for parents to make improvements to their parenting before a council issues care proceedings.

10. The guidance says the council should send the child’s parent/s or guardian a letter at the public law outline stage setting out its concerns.

11. ‘Care proceedings’ mean a council has asked the court to decide who should care for a child. If a court grants a care order, this puts the child in the care of the council.

12. In 2009 and 2014, the government issued guidance for councils about care orders and what councils should do before a court hearing. This says a council should hold a legal planning meeting where it can get legal advice. The council should decide whether the threshold criteria for care proceedings have been met in principle. The council should decide if there should be a period of support for the family to stop proceedings, or if the proceedings should start immediately.

13. There are two thresholds a council can use to start care proceedings: whether there is a risk to the child, or if the child is beyond parental control.

The Human Rights Act

14. The Human Rights Act 1998 sets out the fundamental rights and freedoms that everyone in the UK is entitled to. This includes the right to life, freedom from torture and inhuman or degrading treatment or punishment, liberty and security of person, a fair hearing, respect for private and family life, freedom of expression, freedom of religion, freedom from forced labour, and education. The Act requires all local authorities - and other bodies carrying out public functions - to respect and protect individuals’ rights.

15. Our remit does not extend to making decisions on whether or not a body in our jurisdiction has breached the Human Rights Act – this can only be done by the courts. But we can make decisions about whether or not a body in our jurisdiction has had due regard to an individual’s human rights in its treatment of them, as part of our consideration of a complaint.

16. In practical terms, councils will often be able to show they are compliant with the Human Rights Act if they consider the impact their decisions will have on the individuals affected and that there is a process for decisions to be challenged by way of review or appeal.

17. Article 8 of the Human Rights Act sets out the right to respect for private and family life, home, and correspondence. This applies to cases where an organisation’s actions impact on an individual’s private and family life.

18. In the legal case of Conors v UK (2004), Article 8 rights were described as being:

“of central importance to the individual’s identity, self-determination, physical and moral integrity, maintenance of relationships with others and a central place in the community.”

The Council’s complaints procedure

19. This says:

“If something has gone wrong and the customer has suffered as a result, the Council will consider what action needs to be taken to remedy the situation. The aim is to apologise and to try to put things right … In some circumstances it may be appropriate to consider monetary compensation. In such cases, the service should seek approval from the Service Manager before a final decision is reached. Consideration should also be given to the [Local Government and Social Care Ombudsman’s] Guidance on Remedies.”

Our principles of good administrative practice

20. This document sets out the principles of good administration. One of these is putting things right when something has gone wrong. It says one of the principles is:

“Operating an effective complaints procedure, which includes offering a fair and appropriate remedy when a complaint is upheld.”

Our guidance on remedies

21. This guidance, most recently updated in March 2025, says:

“we decide what injustice has probably resulted from fault we identify and, then, using this guidance, objectively decide what is an appropriate remedy for that injustice.”

22. It also says:

“When, having already considered each of the previous remedy options, we identify there is still significant unremedied injustice arising from the fault(s), we can ask the organisation to make a payment to symbolise and acknowledge the distress or difficulties the person has been put through because of what it did wrong.”

How we considered this complaint

23. We have produced this report following the examination of relevant files and documents and an interview with the complainant.

24. We gave the complainant and the Council a confidential draft of this report and invited their comments. We took their comments into account before completing the report.

Findings

Background

25. Miss X went into labour 13 weeks prematurely. She drove to several hospitals but they did not accept her. Due to the distance between the hospitals and the time this took, there was a delay in Miss X getting medical treatment and a caesarean section. This meant her child, B, was potentially starved of oxygen. B was later diagnosed with a life-long medical condition.

26. B remained in hospital after their birth due to medical complications. B was moved between four different hospitals for medical treatment. B was given blood transfusions which Miss X says she had not consented to. B got an infection. Miss X said one of the blood transfusions caused the infection.

27. Miss X refused to consent to a further blood transfusion, believing a previous one had contributed to B’s health deteriorating further.

What happened

28. In late 2022, when Miss X refused consent for a further blood transfusion, the hospital made a referral to the Council. The hospital was concerned that B’s health would suffer without a blood transfusion and they were therefore at risk of harm.

29. The Council sought legal advice about B and Miss X’s older child, C. The Council had concerns about Miss X refusing treatment for B, that Miss X might not be able to care for B long term, that there had been domestic abuse from B and C’s father, and about Miss X’s mental health.

30. The legal advice was that the threshold for entering the public law outline process was met for B and C. On the same day, a social worker gave a letter to Miss X saying the Council was starting the public law outline process for B and C.

31. In early 2023, the Council completed a child and family assessment. This assessment said there were “currently no significant concerns” about Miss X’s mental health. It said there was a suggestion Miss X had a history of mental ill health from 2014, but it noted that at the time of the assessment the Council did not have the full details. The assessment concluded it was unclear what Miss X’s mental health concerns were, but there were no identified significant concerns about her ability to care for B and C.

32. A week later, there was a multi-agency strategy meeting. Professionals did not agree with each other about whether B and C were likely to suffer significant harm.

33. The Council held a public law outline meeting with Miss X the next day. The Council told Miss X she had to engage with medical professionals or the case would escalate to an initial child protection conference.

34. There was a follow-up strategy meeting the next week. This noted that visits with health professionals had taken place but Miss X could not be present because she had contagious infections. The professionals’ view was that there should be an initial child protection conference on the basis of Miss X’s “disguised compliance and lack of engagement”.

35. Two weeks later, at the initial child protection conference, professionals again did not agree. There was a split decision with half saying the children should be on child protection plans, and the other half disagreeing. The chair of the meeting decided the children should be on child protection plans because the Council had started the public law outline process.

36. Two months later, there was an early review of the child protection plans. The decision was to end the child protection plans for B and C.

37. Two months after this, in August, the Council told Miss X it was ending the public law outline process for B and C.

38. Miss X complained in October.

39. In its first complaint response, sent in November, the Council said it put B and C on child protection plans because the public law outline was in place. But the Council also said it did not believe the information shared within the conference would have met the threshold for a child protection plan on its own.

40. The Council said Miss X’s concerns at the time about whether she could care for B were understandable given the situation. It said it could have been more appropriate for the Council to have offered support. It apologised for any distress caused.

41. The Council listed the reasons it decided to start the public law outline process. This included Miss X’s lack of consent for B’s medical treatment, her engagement with medical professionals, her mental health, and alleged domestic abuse from B and C’s father.

42. In Miss X’s response to the Council, she explained the reason she had refused a blood transfusion for B. She said she had been given conflicting information, had been told B would die, and that B had been wrongly diagnosed.

43. In January 2024, the Council sent its final complaint response. It said key staff involved in the Council’s decisions and actions had left the Council.

44. The Council said there was a lack of context about Miss X’s mental health when it got legal advice. The Council said it could not have determined whether there was any potential impact of Miss X’s mental health on the children without getting more information and without a clear assessment.

45. The Council said the evidence suggested Miss X sought appropriate medical support when needed. It said this should have been seen as a strength not a detriment.

46. The Council apologised that it made judgements about Miss X without proper assessment. It said this meant the advice that the children were at risk of significant harm was wrong. The Council accepted it did not have evidence to suggest that Miss X's mental health could cause harm. It said it should not have accepted the legal advice that the threshold was met on that basis.

47. The Council said there was no evidence of domestic abuse when it sought legal advice. It accepted there was not enough evidence to suggest that C witnessed domestic abuse. It also accepted there was no evidence that C was at risk of abuse.

48. The Council accepted it should not have started the public law outline process. It said it took limited information and found there was a risk without proper assessment. The Council said there was a lack of robust oversight and scrutiny of how professionals decided that Miss X’s mental health was impacting on her care of B and C, and what evidence there was about domestic abuse.

49. The Council said the fact that Miss X did not attend a health visit because she was ill should not have been seen as negative. It said that Miss X choosing to remove herself while ill because B was vulnerable should have been seen as a protective factor. The Council said it did not believe it had evidence of disguised compliance or a lack of engagement by Miss X, poor bonding with B, or poor care of B and C.

50. The Council said C’s school had said that the way professionals were responding to Miss X was having a detrimental impact on the situation.

51. The Council said in hindsight, and with more care, attention and investigation, it did not believe the threshold for child protection plans was met.

52. The Council accepted that communication between professionals was lacking at times. It said this contributed to professionals behaving reactively. It said professionals took information at face value and did not examine the wider context of the situation. The Council said it did not believe it had evidence that Miss X’s decisions about B’s care amounted to any harm, let alone significant harm.

53. The Council said it was unclear whether it had given Miss X the appropriate support and empathy she needed to deal with, and process, everything that had happened and was happening at the time.

54. Miss X had complained that she had concerns about enhanced Disclosure and Barring Service (DBS) checks and future employment. This final stage complaint response said the Council had contacted its DBS team for advice but was still waiting for a response. The Council said it would follow up and provide an answer when it had heard from its DBS team.

55. The Council recognised it needed to learn from what happened. It said it would conduct a learning review to identify where it could make changes to make sure mistakes like this did not happen again. It said it would share its findings with all professionals involved.

56. The Council apologised sincerely for the impact on Miss X, B, C, their wider family, and friends. It recognised the extreme distress and trauma Miss X experienced and continued to experience.

57. In March 2025, the Council emailed Miss X with the response from its DBS team.

The Council’s learning review

58. The Council completed its learning review in August 2024.

59. The report of the review said the Council’s escalation to child protection and public law outline proceedings was because of value judgements that were not evidenced based. The report acknowledged the Council followed its processes quickly and reactively, and it did not hear the professionals who were challenging the Council’s view.

60. The report said there was no evidence to support that Miss X’s mental health would impact negatively on B or C, or adversely affect her parenting capacity. The report said it had become clear that the Council made judgements about Miss X without proper assessment. It said this resulted in advice which wrongly identified that C was at risk of significant harm. It said once an assessment had been completed, there were no significant concerns about Miss X’s ability to care for B or C, and keep them safe.

61. The report said the information shared around domestic abuse contributed to the escalation to the public law outline. The report said there was a significant lack of clarity about why the Council had recorded domestic abuse as a risk.

62. The report said it was crucial for all agencies to share accurate and relevant information. The report said in this case, the information shared around domestic abuse and Miss X’s mental health contributed to the escalation to the public law outline. It said professionals involved have since reflected that there was no evidence to support the information that there was domestic abuse or that Miss X had poor mental health.

63. The report said there was a lack of accurate information sharing between agencies, a lack of understanding of the impact of some statements, and a lack of professional curiosity and reflection which would have uncovered the lack of evidence behind those statements. It said these, taken together, resulted in escalation through Council processes. The report recognised that ultimately the escalation was counterproductive.

64. The report said throughout the assessments and processes, C’s school maintained there were no safeguarding concerns for C. The school also repeatedly said the Council’s escalation to child protection plans and the public law outline was not based on evidence.

65. The report said the school openly challenged the child protection plan. It said that while the school’s views were clearly documented, the Council did not listen to or hear the school’s reflective concerns or opinions. It said the Council should have heard the school’s voice.

66. The report concluded with the following seven recommendations.

• All practitioners should maintain a high level of communication with families and other agencies involved.

• All professionals should explore the family network for every child.

• Professional challenge should be heard and listened to and when agencies do not feel they are being heard, they should follow the escalation process.

• Professionals should be very aware of the language they use. Language should be non-judgemental, not emotive, and not value based.

• It is important to share information with other agencies. Practitioners should make sure to provide information and context for the information sharing. Practice should be evidence based.

• All agencies working with children and families should make every effort to cross reference information to assist with a holistic assessment.

• Senior Council officers will jointly visit Miss X.

67. The report said Miss X and all agencies involved would get a copy of the report. It said it would:

• share the report in the Child Safeguarding Practice review sub-group;

• add the above recommendations to the Council’s action tracker to progress and monitor through the sub-group; and

• escalate any good practice or barriers to the Safeguarding Children’s Partnership board.

68. It is positive the Council undertook this learning review. We find the review was thorough, holistic, and well-balanced and it appropriately focused on the issues that were key to the faults in this case.

69. Due to delays outside the Council’s control, it has not been able to implement the recommendations yet. We are pleased the Council took decisive action to avoid any further drift and delay. It is important that these recommendations are followed up. We address this in the recommendations section below.

Conclusions

Child protection plans

70. Miss X complained the Council wrongly put both of her children on child protection plans.

71. We agree with the Council’s finding that this complaint was upheld on the basis that it made judgements about Miss X without proper assessment, and the advice that the children were at risk of significant harm was wrong. The Council said in hindsight it did not believe the threshold for child protection plans was met.

72. We find the Council at fault. We find this fault caused Miss X injustice because it caused unnecessary and avoidable distress as she described, frustration, and uncertainty.

Care proceedings

73. Miss X complained the legal threshold to consider care proceedings was not met.

74. We agree with the Council’s finding that this complaint was upheld on the basis that it took limited information and formed a judgement of risk without properly assessing what this meant in terms of the impact on B and C. The Council accepted there was a lack of robust oversight and scrutiny of how professionals reached their views.

75. The Council said it did not have evidence to suggest Miss X’s mental health could be considered to cause significant harm. It said therefore it should not have accepted the legal advice that the public law outline threshold was met on that basis.

76. We find the Council at fault. We find this fault caused Miss X injustice because it caused unnecessary and avoidable distress as she described, frustration, and uncertainty.

Mental health

77. Miss X complained the Council wrongly claimed she had mental health issues, and used this incorrect information in its assessments.

78. We agree with the Council’s finding that this complaint was upheld on the basis that there was no evidence of mental health concerns or a mental health diagnosis for Miss X. The Council said it made judgements about Miss X’s mental health without proper assessment. It said this resulted in advice that C was at risk.

79. The Council said it did not have evidence to suggest Miss X’s mental health could be considered to cause significant harm. The Council said therefore it should not have accepted the legal advice that the public law outline threshold was met on this basis.

80. We find the Council at fault. We find this fault caused Miss X injustice because it caused unnecessary and avoidable distress as she described, frustration, and uncertainty.

Domestic abuse

81. Miss X complained the Council wrongly claimed her children’s father was abusive, and used this incorrect information in its assessments.

82. We agree with the Council’s finding that this complaint was upheld on the basis that it had no evidence of domestic abuse when it sought legal advice about the public law outline process. It accepted it did not have enough evidence to suggest that C witnessed domestic abuse. It also said there was no evidence C was at risk of abuse.

83. We find the Council at fault. We find this fault caused Miss X injustice because it caused unnecessary and avoidable distress as she described, frustration, and uncertainty.

Communication

84. Miss X complained the Council communicated poorly with her and with other agencies.

85. Miss X told the Council that when the social worker gave her the letter about the public law outline process they did not explain what this meant or why the process was being implemented. In its complaint responses, the Council accepted that this happened. The Council also accepted it had communicated poorly with Miss X and other agencies.

86. We agree with the Council’s finding that this complaint was upheld on that basis and we find it at fault. We find this fault caused Miss X injustice because it caused unnecessary and avoidable distress, frustration, and uncertainty.

87. As we have said above, Miss X complained that she had concerns about enhanced Disclosure and Barring Service (DBS) checks and future employment. The final stage complaint response dated January 2024 said the Council had contacted its DBS team for advice but was still waiting for a response. The Council said it would follow up and provide an answer when it had heard from its DBS team.

88. The Council emailed Miss X with the response from its DBS team in March 2025, over a year later. It apologised for the delay. The Council said this delay was because the member of staff responsible for this was absent.

89. This delay of one year to provide this information is fault. We find this fault caused Miss X injustice because it caused uncertainty.

Level of intervention

90. Miss X complained the Council excessively and disproportionately intervened.

91. We agree with the Council’s finding that this complaint was upheld on the basis that in hindsight B and C should not have been placed on child protection plans and the legal threshold for the public law outline process was not met.

92. The Council accepted that at the initial child protection conference, C’s school clearly identified that the way professionals were responding to Miss X was having a detrimental impact on the situation.

93. The Council also accepted that the school had the longest relationship with Miss X and the family. The Council said the school spoke positively about Miss X’s care of C at the initial child protection conference. The school did not agree that C needed a child protection plan.

94. The Council said if the circumstances around B’s birth and later diagnosis had not been so traumatic, it did not believe Miss X would have come to the Council’s attention.

95. We find the Council at fault.

96. Miss X said the Council’s excessive and disproportionate intervention traumatised her. She said she felt shamed and misjudged. She said she was treated like a danger to her children during one of the most frightening, exhausting and vulnerable times of her life. Miss X said she and her children carry the emotional consequences every day.

97. We find this fault caused Miss X injustice because it caused unnecessary and avoidable distress as she described, frustration, and uncertainty.

Other conclusions Complaint handling

98. We find evidence of good complaint handling. The Council’s final complaint response was thorough and well-balanced, and it accepted fault and injustice. The Council apologised for the injustice caused by the fault.

99. However, we also find some fault in the complaint handling.

100. The final stage complaint response did not consider a financial remedy for the unnecessary and avoidable significant distress, frustration, and uncertainty (the injustice) caused by the Council’s faults.

101. The Council told us it is not standard practice to offer “compensation” as part of the complaints process unless the complainant incurred a quantifiable loss.

102. This statement is not in line with the Council’s complaints procedure, which says, “in some circumstances it may be appropriate to consider monetary compensation” and it should consider our guidance on remedies.

103. This statement is also not in line with our principles of good administrative practice. One of the principles of putting things right when something has gone wrong is to operate an effective complaints procedure, “which includes offering a fair and appropriate remedy when a complaint is upheld”.

104. The Council said Miss X asked for financial compensation. It said it considered her request and offered her £4,000 to recognise the distress caused. It said Miss X declined this offer.

105. The Council said it referred Miss X to its insurance team and advised her to seek legal advice about her claim for compensation.

106. We do not award “compensation”. We decide what injustice has probably resulted from fault we identify and then objectively decide what is an appropriate remedy for that injustice using our guidance on remedies. Our payments are symbolic.

107. We have considered the Council’s offer of £4,000 to reflect the distress caused. We have also considered our guidance on remedies. This sets out a usual maximum of £500 for unnecessary and avoidable distress, frustration and uncertainty. In exceptional circumstances such as these, where Miss X was vulnerable after a traumatic birth and the Council’s actions caused severe distress and have had a lasting impact, we can recommend a higher figure. As the Council has offered a symbolic payment which is significantly more than what we would normally offer, and this reflects the significant injustice to the family, we have decided not to recommend an additional financial remedy.

Human Rights

108. As we have said above, Article 8 of the Human Rights Act applies to cases where an organisation’s actions impact on an individual’s private and family life.

109. We find that Article 8 is engaged here because of the Council’s excessive and disproportionate level of intervention. We find the Council did not consider the impact its decisions would have on Miss X. Therefore, we find the Council failed to have due regard to its duties under Article 8 of the Human Rights Act.

Recommendations

110. The Council must consider the report and confirm within three months the action it has taken or proposes to take. The Council should consider the report at its full Council, Cabinet or other appropriately delegated committee of elected members and we will require evidence of this. (Local Government Act 1974, section 31(2), as amended)

111. In addition to the requirements set out above the Council has agreed to take the following actions to remedy the injustice identified in this report.

112. Miss X wants a formal apology from a senior level within the Council to acknowledge the faults and the impact they had. We consider a further apology, given by a more senior officer, is appropriate and proportionate given the level of injustice caused. Therefore, we recommend that within four weeks of the date of this report a senior officer apologises in writing to Miss X.

113. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making this apology.

114. We also recommend that within four weeks of the date of this report the Council makes a payment to Miss X of £350. This is to remedy the uncertainty caused by the year of delay in providing information to her about Disclosure and Barring Service checks (see paragraphs 87 to 89).

115. In arriving at this figure, we have considered our guidance on remedies. This sets out a maximum of £500 to remedy uncertainty. We have taken into account the importance of this information to Miss X and that she waited a year for it. For these reasons, we consider a payment of £350 is appropriate and proportionate to the level of injustice caused.

116. We also recommend the Council keeps its offer of £4,000 open to Miss X (see paragraphs 104 to 107). It is Miss X’s decision whether to accept it.

117. To improve its services, within three months of the date of this report the Council has agreed to provide evidence that:

• the learning review report was shared in the Child Safeguarding Practice review sub-group;

• the recommendations from the learning review report have been added to the action tracker for progress and monitoring through the sub-group; and,

• the recommendations from the learning review report have been tracked and monitored and, where appropriate, continue to be tracked and monitored so the learning is embedded in practice.

118. We will need to see evidence that these actions have been completed.

Decision

119. We find fault causing injustice. The Council has agreed to take actions to remedy injustice and improve its service.

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