Summary: Mrs X complains the Council did not deal with a child protection issue properly, resulting in avoidable distress. The Council is at fault because it failed to deal with a child protection issue and took too long to investigate. Mrs X and her family suffered delay and avoidable distress. The Council should pay Mrs X £500 for time and trouble, pay Mrs X £2000 for avoidable distress and re-issue its final written response to the investigation.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council failed to deal with a child protection complaint properly because:
• it failed to handle an allegation of abuse between her children correctly;
• took too long to deal with her complaint; and
• hasn’t properly implemented the complaint process recommendations as the remedy offered doesn’t reflect the impact on her family
2. Mrs X says she and her family suffered avoidable distress.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. 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)
5. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).

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How I considered this complaint

6. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
7. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Law, guidance and policies

8. 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)
9. 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.
10. Councils should act decisively to protect children from abuse and neglect including starting care proceedings where existing interventions are insufficient.
11. 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.
12. 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.
13. 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”.
14. 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) and implementing a safety plan.
15. When cases involve parallel criminal and child protection investigations, a police investigation will focus on whether there is sufficient evidence to prove beyond reasonable doubt that a crime has been committed. Child protection enquiries seek to find out, on the balance of probabilities whether a child is at risk of significant harm.
16. When a council has concerns about a child, the law requires it to take action to find out more. It only has to have ‘reasonable cause to suspect’. This is a lower burden of proof than that used by the Police or the Courts who require evidence ‘beyond reasonable doubt’.
17. Statutory Complaints Process
18. 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. We also published practitioner guidance on the procedures, setting out our expectations.
19. The first stage of the procedure is local resolution. Councils have up to 20 working days to respond.
20. 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 investigating officer (IO) to look into the complaint and an independent person (IP) who is responsible for overseeing the investigation and ensuring its independence.
21. Following the investigation, a senior manager (the adjudicating officer) at the council should carry out an adjudication. The officer considers the IO report and any report from the IP. They decide what the council’s response to the complaint will be, including what action it will take. The adjudicating officer should then write to the complainant with a copy of the investigation report, any report from the independent person and the adjudication response.
22. The whole stage two process should be completed within 25 working days but guidance allows an extension for up to 65 working days where required.
23. 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 working days of the date of request, and then issue a final response within 20 working days of the panel hearing.
24. Within 15 working days of receiving the panel’s recommendations the local authority must consider the recommendations and determine (a) how the authority will respond to them; and (b)what they propose to do in the light of them, and send to the complainant its response and proposals, along with information about making a complaint to a Local Commissioner. (The Children Act 1989 Representations Procedure (England) Regulations 2006 s20(3))
25. The statutory children’s complaints procedure was set up to provide children, young people and those involved in their welfare with access to an independent, thorough and prompt response to their concerns. Because of this, if a council has investigated something under the statutory children’s complaint process, the Ombudsman would not normally re-investigate it.
26. However, we may look at whether there were any flaws in the stage two investigation or stage three review panel that could call the findings into question. We may also consider whether a council properly considered the findings and recommendations of the independent investigation and review panel, and whether it has completed any recommendations without delay.

What happened?

27. This is a brief chronology of key events. It does not contain everything I reviewed during my investigation.
28. Mrs X lived with her partner and three children, A, B and C.
29. In June 2022 C’s school made a safeguarding referral after C disclosed an incident.
30. A Strategy meeting was held, resulting in a joint section 47 enquiry being undertaken.
31. The children were put on a child protection plan in September 2022.
32. Mrs X complained to the Council about the way the case was handled and the impact this had on the children and the whole family.
33. C had to live with his biological father, who lived separately.
34. In March 2023 the case was then stepped down to Child in Need.
35. The Council upheld Mrs X’s complaint and made a number of recommendations.

Analysis

Investigation findings

36. I have considered the investigation report and stage 3 panel findings. Some of the key comments from which are included below:
• there was at best a lapse in communication and at worst, decision making that was reactionary followed by significant drift and delay in decision making underpinned by poor communication with the family.
• This must have been a very distressing time for all of the family but particularly for the children who I am sure were left confused and worried.
• the circumstances under which C returned to his family home were markedly similar to those under which he left. All decision making should be explained carefully to families when we are taking action to separate sibling groups and undertake actions designed to safeguard children. It is my view that this did not happen in this situation.
• There was undue delay in completing the investigative process and that there was poor communication with the family about the progress of the investigation and the outcome.
• there was a significant delay from the point of C’s initial disclosure to a decision being made that one of the children needed to leave the family home.
• this must have been extremely confusing and distressing for the family
• with a lack of risk assessment, safety planning and close management overview, the situation was allowed to significantly drift unnecessarily.
• the frequency of visits to assess and discuss risks and safety planning with the family, were inadequate.
• communication fell below the standards that we would expect from our practitioners and in line with our Restorative Practice Framework.
• we had a family who were deeply affected by very serious allegations that should have benefitted from an open, honest, transparent approach to thoroughly assessing all aspects of the children’s lives and functioning to then determine risk, both now and into the future. I also agree that there was a lack of professional curiosity applied about what the information we had meant and what the future of the sibling group looked like. We could have and should have safety planned from the beginning, in a way that ensured the children’s safety and as little disruption as possible to the family unit. I am sorry that we did not do this.
• the way that this situation has been handled will likely have a lasting impact on the family.
• The following concerns were identified in this investigation:
1. there was drift and delay in the management of the case by the Council;
2. a lack of professional curiosity leading to concerns being viewed in isolation;
3. the decision to proceed to an ICPC prior to the completion of the second s.47 enquiry;
4. agreed actions not being completed by professionals resulting in missed opportunities;
5. potential for putting S and other children at risk of harm due to the lack of risk assessments;
6. absence of crucial decision-making records and management oversight throughout to justify the actions taken;
7. unnecessarily prolonged delays to allowing C to return home and no evidence of a risk assessment being completed despite DCC having advance notice that C would be returning home;
8. lack of sufficient progress in carrying out meaningful work to reduce the concerns;
9. insufficient number of visits to the children;
10. inadequate support for the children;
11. delays in the communicating the outcome of the police investigation to agencies involved
12. Process was not followed and outcomes were determined prior to clear assessments and risk assessments having taken place. Changes in social work personnel can contribute to drift and delay, inconsistent decision making and what we refer to as “the golden thread of risk” becoming lost. I do agree that changes in social worker and manager may have negatively impacted upon the timeliness of decision making for your children and for this I am truly very sorry.
37. The Council accepts there were significant failing in the way the investigation was conducted. This is fault by the Council. Mrs X and her family suffered avoidable distress.

Complaint Handling

38. Mrs X first complained in October 2022. The Council sent a stage one complaint response the same month.
39. Mrs X contacted the Council in December 2022 requesting to escalate her concerns to Stage 2. The Statement of Complaint was agreed after very considerable delay in July 2023.
40. There was a long delay in the investigation process. The Council’s stage two complaint response was provided in August 2024.
41. This was some 20 months after the request to escalate matters to Stage 2 and 13 months after the agreed Statement of Complaint was signed off in July 2023.
42. Mrs X requested her complaint be escalated to stage three in September 2024. The stage three panel hearing was held in October 2024. The stage 3 panel upheld the entirety of Mrs X’s complaint.
43. The Council’s final response was sent to Mrs X in November 2024.
44. The Council accepts here was excessive delay in completing the complaints process. This is fault by the Council. Mrs X and her family have incurred time and trouble through the delay and the avoidable distress they suffered has been exacerbated.

Disagreement with the stage 3 panel

45. Part 6 of Mrs X’s complaint concerned why the two of her children who were included in the original safeguarding disclosure were not separated immediately.
• The stage 2 investigation partially upheld this complaint, stating there should have been better communication with the family.
• The stage 3 panel disagreed and fully upheld this part of Mrs X’s complaint.
• The Council disagreed and reversed this finding in its final written response.
46. As set out in paragraph 23, the Council cannot dispute the findings of the stage 3 panel. The regulations only allow the Council to disagree on the recommendations, there is no provision to allow it to disagree with the findings. This is fault.

Recommendations

47. The stage two investigation made 15 recommendations, which the Council responded to outlining action that had been or would be taken. These included:
• A face to face meeting to offer a formal apology;
• Offer the children a meeting with a professional or service to help them recover;
• Risk assessments for safety plans;
• Amending processes where cases are reallocated;
• Improve administration and record keeping;
• Offers of advocacy for children;
• Support to Mrs X’s children;
• Expert professional assessments;
• Best practice and multi-agency working;
• Consideration of financial support where arrangements are made for child to live somewhere else;
• Frequency of visits to children subject to a Child in Need plan; and
• Training for staff about speaking to children.
48. The stage three panel made 4 recommendations:
• The Council review the complaint procedure within 3 months to ensure it includes where there may be a significant delay, particularly at Stage 2, that they will actively consider the reallocation of the investigative process to ensure timeliness of completion.
• The Council should consider in line with the Local Ombudsman Remedies Guidance payment for the severe delay in completing this complaint.
• The Council should consider in line with the Local Ombudsman Remedies Guidance payment for the acknowledged distress caused to the family by the poor management of the situation and should also look at reimbursing Mrs X with costs of the transport to and from school for the elongated period that he was living with his maternal grandmother.
• The Council should ensure its quality assurance programme robustly tests the frequency of visiting and quality of recording in child protection investigations to achieve best practice.

Action by the Council

49. The Council responded to the stage three panel recommendations stating it would consider the reallocation of investigations where significant delays are encountered, offer a payment of £250 in respect of delays to the statutory complaints process, offer a payment of £250 in respect of distress caused by poor management of the situation and review its quality assurance programme.
50. The Council says it has offered Mrs X an assessment for her children to determine the appropriate therapeutic input, a face to face meeting to apologise and for her complaint to be used as a case study to aid learning.
51. The Council says it has made the following service improvements as a result of Mrs X’s complaint:
• Training on Safety Planning and Contingency Planning;
• Auditing of case recording quality;
• Review of processes including a new child protection plan template.
52. I have seen evidence of the audit process, template and the Council’s quality assurance programme. I consider this to be an appropriate remedy in respect of service improvements.

The Ombudsman’s Guidance on Remedies

53. Symbolic payments are usually for injustice in the form of:
• distress – significant anxiety, frustration, upset or pain. A payment for distress will reflect more than simple inconvenience or moderate disappointment with flawed actions/ inactions;
• time and trouble – this should be used for injustice from mistakes in how the organisation considered the complaint (for example taking much too long, avoidably requiring repeated follow ups.)
54. When we assess distress, we consider the complainant’s individual circumstances (such as their health, age, and financial circumstances). In deciding a remedy we will consider the complainant’s assessment of distress or inconvenience they have suffered.
55. Our recommendation for a remedy needs to reflect all the circumstances including:
• the severity of the distress;
• the length of time involved;
• the number of people affected (for example, members of the complainant’s family as well as the complainant);
• whether the complainant or other persons affected are vulnerable and affected by distress more severely than most people; and
• any relevant professional opinion about the effects on any individual.
56. Where we decide it is appropriate, we will normally recommend a remedy payment for distress of up to £500. We can recommend higher payments to remedy distress where we decide it was especially severe and/or prolonged and/or taking account of personal vulnerability of those affected.
57. The remedy payment for time and trouble is likely to be up to £500.
58. I have considered all the factors above and an impact statement from Mrs X. I do not consider the Council’s financial remedy offers to be sufficient or appropriate. Due to the number of people affected in her family, the extended time taken to resolve the investigation process and the impact on Mrs X and one of her children in particular, I am recommending a symbolic payment for distress which is in excess of the Ombudsman’s normal range.

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Action

59. To remedy the outstanding injustice caused by the fault I have identified, the Council has agreed to take the following action within 4 weeks of this decision:
• Pay Mrs X £500 in respect of time and trouble relating to the delays to the investigation.
• Pay Mrs X £2,000 in respect of avoidable distress to herself and her family.
• Re-issue its written response to the stage 3 panel’s findings.
60. The Council should provide us with evidence it has complied with the above actions.

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Decision

61. I find fault causing injustice. The Council has agreed actions to remedy injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman