Summary: Ms X complained about the Council’s handling of a safeguarding investigation following the death of her baby. She said it failed to include critical medical evidence in its safeguarding report. The Council was not at fault. It carried out the safeguarding enquiry in line with relevant law and policy.

The complaint

1. Ms X complained the Council failed to include critical medical evidence in its safeguarding report that would have led to her unborn child’s death being classified as a ‘stillbirth’. Instead, the Council carried out a safeguarding investigation into the death in which Ms X said it failed to:
• focus on her older daughter but instead concentrated on the circumstances surrounding her unborn baby’s death;
• apply its FaST (Finding Solutions Together) resolution process to address conflicting accounts of the events; and
• handle her complaint in accordance with its corporate complaints policy.
2. Ms X stated if her baby’s death had been correctly recorded as a ‘stillbirth’, the Council would not have conducted such an intrusive investigation into her private life. Ms X wants the Council to revise its safeguarding records and acknowledge to the coroner that key medical evidence was omitted from its report.

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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(1), as amended)
4. 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 how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)

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What I have and have not investigated

5. We investigate complaints about councils and certain other bodies. We cannot investigate the actions of bodies such as the Police and health services. (Local Government Act 1974, sections 25 and 34(1), as amended)
6. I have not investigated the actions or reports submitted by hospital staff or the ambulance service to the Council. Likewise, I cannot investigate the coroner’s ruling.
7. I have investigated the aspects of Ms X’s complaint that concern the Council’s actions in relation to the safeguarding investigation. This includes why the Council did not apply its FaST process as a remedial mechanism in cases of disagreement, and why it failed to escalate Ms X’s complaint to stage two of its corporate complaints procedure.

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How I considered this complaint

8. I considered evidence provided by Ms X and the Council as well as relevant law, policy and guidance.
9. Ms 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

Relevant law and guidance

Child Protection - Duty to Investigate

10. 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)

Acting on a referral and Section 47 requirements

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.

Child Protection Conference arrangements

15. If, following a referral and an assessment by a social worker, a multi-agency strategy meeting decides the concerns are substantiated and the child is likely to suffer significant harm, the council convenes a Child Protection Conference.
16. The 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.
17. After the Initial Child Protection Conference, 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.
18. Review Child Protection Conferences should be held within three months of the initial conference, and thereafter at maximum intervals of six months.
19. The Child Protection Conference is a multi-agency body and is not in itself a body in the Ombudsman's jurisdiction.
20. The Child Protection Conference plays an advisory role. But the final decision, for example whether to place a child on a Child Protection Plan or to discontinue a Plan, is the responsibility of the council. We would generally consider it appropriate for a council to follow the recommendations of the Child Protection Conference unless there was good reason not to.

Reasonable cause to suspect versus beyond reasonable doubt

21. 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’.

Child Death Review

22. In accordance with the statutory guidance Working Together to Safeguard Children (2023) Child death review partners must make arrangements for the analysis of information from all deaths reviewed. The purpose of a review and/or analysis is to identify any matters relating to the death, or deaths, that are relevant to the welfare of children in the area or to public health and safety, and to consider whether action should be taken in relation to any matters identified. If child death review partners find action should be taken by a person or organisation, they must inform them.

Joint Agency Response (JAR):

23. A JAR is a coordinated multi-agency response by the named nurse, police investigator, duty social worker and should be triggered if a child dies:
• is or could be due to external causes;
• is sudden and there is no immediately apparent cause (including sudden unexpected death in infancy/childhood (SUDI/C);
• occurs in custody, or where the child was detained under the Mental Health Act;
• where the initial circumstances raise any suspicions that the death may not have been natural; or
• in the case of a stillbirth where no healthcare professional was in attendance.

The Council’s FaST process:

24. This process is to be used by professionals involved in cases when a child is judged to be at risk of harm or is unsafe. The Surrey FaST (Finding Solutions Together) resolution process has been agreed with the Council’s partners, as a mechanism for seeking solutions when a child is at risk but other processes such as making a referral to the Council and/or discussing concerns directly with the agency concerned, has not achieved a mutually agreeable resolution. It is a process used by professionals where in particular there is a disagreement for example, around threshold and decision making.

The Council’s Corporate complaints procedure

25. The Council has a separate complaints procedure for children’s social care complaints. It is three stage statutory procedure, and it allows ten working days (extendable to 20 if necessary) for a response at stage one.
26. On its website it the Council encourages complainants to speak or meet with the team manager of the service they are complaining about.

What happened

27. Ms X has a child and was pregnant in early 2024 with another baby. In May, Ms X went into the early stage of labour. She remained at home intending to deliver the baby there with the support of a midwife. She experienced complications which meant the midwife called an ambulance and Ms X was admitted to hospital. The baby was delivered showing no signs of life. Ms X remained in hospital seriously ill.
28. Ms X said she was in contact with her midwife during the pregnancy and about ten days prior to going into labour she said her midwife was uncertain if she could hear the baby’s heartbeat. She also said the ambulance report stated the baby was stillborn.
29. However, hospital staff recorded that the baby died during the birthing process and notified Children’s Social Care. It recorded the child’s death in the Joint Agency Response (JAR) Workbook.
30. JAR is a coordinated multi- agency response and is triggered when a child dies. As a result, the Council made initial enquiries and decided to hold a strategy meeting. At the meeting, it was noted that no death certificate had been issued, as the baby’s cause of death was unknown. The case was therefore referred to the coroner. The professionals present at the strategy meeting reached a unanimous decision that the Council should initiate a child protection investigation and carry out a child and family assessment. It said it was important at the time to understand Ms X’s other child’s overall well-being who at the time of Ms X’s labour was looked after by their maternal grandmother.
31. Following the child and family assessment a Child Protection Conference (CPC) took place in June.
32. The outcome of the CPC was that the threshold for a child protection plan for Ms X’s older child was not met. No further actions were required and the case closed.
33. In October, Ms X complained to the Council. She stated that the Council asked unnecessary and intrusive questions into her baby’s death instead of focussing on her older child’s overall well-being. She also said the Council had failed to include information from the ambulance report which had recorded that the baby was stillborn.
34. In its November response, the Council said it was required to consider all family members and the circumstances of the baby’s death during the child and family assessment which is why the process might have felt intrusive. It explained it used the hospital referral as a source to inform its safeguarding report. It could not comment on why the hospital referral did not include the ambulance report stating the baby was stillborn.
35. In December, Ms X asked for her complaint to be escalated to stage two. The Council declined to investigate further through its complaints process as it could not answer questions relating to the actions of other agencies and it was not in a position to comment on their behalf. Instead, it offered Ms X a face-to-face meeting to discuss its own actions. Ms X did not take up the Council on its offer for an in-person meeting.
36. In January, Ms X escalated her complaint to the Council’s Chief Executive. Although the Council responded, it declined to subsequently answer her further questions.
37. In March, Ms X remained dissatisfied, and complained to us. She said the Council should have used its FaST process which she said exists to prevent wrongful safeguarding escalations. She said the Council’s failure to apply the FaST process led to the Council’s unnecessarily initiating a safeguarding investigation.

My findings

38. A Joint Agency Response (JAR) is triggered following any child’s death. This multi-agency process led to the Council being informed of Ms X’s child’s death. Consequently, the Council had a duty to make initial enquiries and held a strategy meeting. In that meeting, the involved professionals from various agencies decided to initiate a child protection investigation which required the Council to carry out a child and family assessment. It acknowledged that it needed to ask difficult questions during the assessment but explained this was necessary to gain a full understanding of the family’s circumstances. The Council acted in accordance with the law and was required to make such enquiries. I therefore find no fault in the Council’s decision to initiate a child protection investigation or in the way it carried out the assessment.
39. Ms X believed the Council should have used its FaST process, which she said was designed to prevent unnecessary safeguarding enquiries. However, the FaST process is a professional tool used within the Surrey Safeguarding Children Partnership; it is not intended for situations where a family disagrees with the safeguarding process. In this case, professionals at the strategy meeting unanimously agreed to initiate a child protection investigation. As there was no disagreement, the Council was not required to apply the FaST process. I find no fault in the Council’s decision and therefore cannot question the outcome.
40. The Council informed Ms X that it could not comment on the actions of other agencies. When she asked to escalate her complaint to stage two, the Council instead offered a face-to-face meeting. Following our enquiries, the Council explained it could only address matters within its own remit and could not fully answer Ms X’s concerns, as these included issues relating to other agencies. I find no fault in the Council’s decision not to escalate the complaint to stage two. It is open for Ms X to complain to the relevant NHS Trust if she is unhappy with how it handled the Ambulance report and referral to the Council.

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Decision

41. I have completed my investigation finding no fault in how the Council carried out its safeguarding investigation.

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Investigator's decision on behalf of the Ombudsman