Summary: We found fault by the Council and Trust with regards to how they handled a child protection medical examination for Miss B. This caused Miss B and her mother, Mrs X, distress and confusion. The Council and Trust will apologise and take action to prevent similar problems occurring in future. They will also pay Miss B and Mrs X a symbolic remedy in recognition of the injustice caused to them.

The complaint

1. The complainant, Mrs X, is complaining about the care and support provided to her daughter, Miss B, by Royal Borough of Kensington and Chelsea (the Council) and Imperial College Healthcare NHS Trust (the Trust). Specifically, Mrs X complains that the Council and Trust failed to follow the correct protocols when undertaking a child protection medical examination for Miss B in June 2024.
2. Mrs X complains that:

• neither the Council nor Trust informed her or her daughter that Miss B would need to be fully undressed for the examination;
• she was not allowed to attend the examination with Miss B;
• neither the examining doctor nor the attending social worker halted the examination when her daughter became distressed; and
• neither the Council nor the Trust took responsibility for these failings, instead blaming each other in response to her complaints.

3. Mrs X says the examination was extremely distressing for Miss B. Mrs X also says she found the complaints process very frustrating as the Council and Trust refused to take responsibility for what had gone wrong and did not respond to her questions and complaints openly and honestly.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
5. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
6. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
7. We cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. 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, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
8. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
9. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

10. I considered evidence provided by Mrs X and discussed the complaint with her. I also considered relevant information and records from the Council and Trust. I took account of relevant law, policy and guidance.
11. All parties had an opportunity to comment on my draft decision. I considered all comments before making a final decision.
12. 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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What I found

Relevant guidance and legislation

Child protection

13. 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.
14. 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.
15. The government has issued statutory guidance to councils managing cases where there are concerns about a child’s safety or welfare. This is entitled ‘Working Together to Safeguard Children 2023 (the Statutory Guidance)’:
16. The Statutory Guidance places an emphasis on strong partnerships between parents or carers and the practitioners working with them. It also highlights the importance of strong multi-agency working to identify and respond to the needs of children and families.

Royal College of Paediatrics and Child Health

17. The Royal College of Paediatrics and Child Health (RCPCH) produces guidance for NHS organisations carrying out child medical examinations. This is entitled ‘Good practice service delivery standards for the management of children referred for child protection medical assessments (2020)’ (the RCPCH Guidance).
18. The RCPCH Guidance says that informed written consent should be taken from a person with parental responsibility for each child protection medical examination.
19. The RCPCH Guidance requires child protection medical examinations to be carried out by appropriately qualified clinicians and with an appropriate chaperone present. The Guidance also says that the child and family should be provided with appropriate support.
20. The RCPCH Guidance says children and young people should be given a choice about who accompanies them in the medical examination. This includes deciding not to have a relative or social worker present.

General Medical Council

21. The General Medical Council (GMC) provides guidance for clinicians around caring for children and young people. This is entitled ‘Protecting children and young people’ (the GMC Guidance).
22. Sections 63 and 64 of the GMC Guidance emphasise that a doctor must be satisfied the person giving consent for a medical examination understands the purpose of the examination and what it will involve.

Background

23. In 2024, Mrs X was living at home with her daughters, Miss B and Miss C. The children also visited their father, Mr Y, regularly and sometimes stayed overnight.
24. In May 2024, the children were staying with Mr Y. Mr Y contacted Mrs X to report that Miss B had sustained bruising to her face. He emailed Mrs X a photo of the bruising. Mrs X made a GP appointment for Miss B but said Mr Y refused to take Miss B.
25. Mrs X said the children were crying and shaking when she collected them. She said they told her Mr Y had caused the injury by pushing Miss B over and causing her to bang her head on the bed or bedside table. However, Mr Y said the injury had been caused either by Miss C striking Miss B with a book, or by Miss B falling into a bedpost.
26. Mrs X subsequently took Miss B to see a GP. The GP noted significant bruising but had no neurological concerns. Miss B told the GP that she could not remember how she had sustained the bruising. She told the GP she had woken up and found her face to be tender. She then looked in a mirror and saw the bruising.
27. Mrs X contacted the Council to raise a safeguarding concern. She expressed the view that Mr Y had caused the injury to Miss B.
28. The Council convened a safeguarding strategy meeting and decided to make section 47 enquiries. As part of this process, the Council made a referral for Miss B to the Trust for a child protection medical examination.
29. The medical examination took place in June. Two doctors were present, along with a social worker. By this point, Miss B’s bruising had gone. The examining doctor noted that Miss B was unable to explain how she had sustained the injuries to her face. The doctor concluded that, as there was no clear explanation for how the bruising occurred, it was not possible to rule out a non-accidental injury.
30. Later that month, the children were placed on a Child Protection Plan. This was due to concerns that the challenging relationship between Mrs X and Mr Y might be having a negative effect on them.
31. Mrs X complained to the Council in September 2024. She said she had not been made aware that Miss B would be required to undress completely for the examination or that her genitalia would be examined. In addition, Mrs X said the social worker who was present failed to intervene to stop the examination when Miss B became upset.
32. The Council acknowledged Miss B had been required to undress and said the social worker who was present had not been aware this would be necessary. The Council said it would refer the matter to the Trust for further consideration.
33. The Trust said the examining doctor had examined Miss B’s skin for any evidence of bruising. However, it said the doctor had not specifically examined Miss B’s genital region. The Trust said it followed the correct procedure for the examination.
34. Mrs X subsequently complained to the Ombudsmen.

My analysis and findings

Medical examination

35. Mrs X complained that she was not allowed to attend the examination. She also said that nobody made her aware that Miss B would need to undress completely. Mrs X said this caused Miss B significant distress. Despite this, Mrs X said neither the social worker nor the examining doctor stopped the examination.
36. In May 2024, Mrs X raised concerns that Miss B’s injury may have been non-accidental in nature. Section 47 of the Children Act 1989 placed a duty on the Council to gather information to help it decide whether any action was needed to safeguard Miss B. The first stage of this process was the safeguarding strategy meeting. The professionals present agreed a child medical examination was indicated.
37. The evidence shows a social worker did discuss the medical examination with Mrs X in advance of the appointment to gain her consent. However, the Council acknowledged that the social worker was not aware what the examination would entail.
38. Mrs X attended hospital with Miss B for the examination. She spoke to the examining doctor before the examination took place and signed a consent form. There is no note of this conversation in the records. In its response to my enquiries, the Trust said the examining doctor recalled explaining to Mrs X what would happen. However, this is contradicted by Mrs X’s account, in which she says she understood the doctor would only be examining the bruise on Miss B’s face.
39. The medical examination then proceeded. The examining doctor was present, along with another doctor who acted as a chaperone. In addition, the social worker was present. Again, there is a significant disparity surrounding the course of events. In its response to my enquiries, the Trust said Miss B had not been required to undress completely and that she kept her underwear on at all times. This is directly contradicted by the social worker’s account as provided by the Council. The social worker said Miss B had been asked to remove her underwear and had done so.
40. The evidence is similarly confused with regards to whether Miss B became upset during the examination. The Trust said the examining doctor did not recall Miss B becoming upset and would have stopped the examination if this was the case. The social worker said Miss B was “shocked” rather than upset and did not become upset until afterwards when a blood test was taken. The examining doctor’s report makes no mention of Miss B becoming upset, recording only that she was “an interactive child”.
41. The examination found the bruising to Miss B’s face had by this point healed and noted no other significant injuries. When asked how she had sustained the injury, Miss B said she could not remember and had woken up to see the bruising in the mirror. The examining doctor ultimately concluded that, in the absence of a compelling explanation for how the bruising occurred, it was not possible to rule out a non-accidental cause.
42. I am satisfied, based on the evidence I have seen, that the Trust ensured an appropriate chaperone was present for the examination in keeping with the requirements of the RCPCH Guidance. I am also satisfied the examining doctor kept an appropriate record of his clinical findings. This included taking information from Mrs X and Miss B, including Miss B’s medical and family history, and an account of the events leading up to the examination. Again, this was in keeping with the RCPCH Guidance.
43. However, the RCPCH Guidance also emphasises the importance of obtaining informed consent for a child protection medical examination. The evidence I have seen suggests there was significant confusion surrounding the examination and what this would entail. This lack of clarity meant Mrs X could not provide informed consent. This is because Mrs X’s understanding of what would happen (as well as that of the social worker) was in direct contradiction with that of the examining doctor.
44. This was an extremely sensitive situation that required all parties to have a clear understanding in advance of what the examination would entail. This did not happen. This was fault. In my view, responsibility for this fault is shared by the Council and Trust. Both organisations had a responsibility to ensure Mrs X and Miss B had a clear understanding of the examination process. I note the Trust says the examining doctor discussed the examination with Mrs X. However, no record of this conversation was kept and so it is not possible to establish what was discussed.
45. There is similar confusion surrounding whether Miss B was asked to undress completely during the examination, with contradictory accounts provided to me by the Trust and Council on this point. This should also have been clearly recorded (in the examining doctor’s report). The fact that it was not represents further fault by the Trust.
46. We are left, therefore, with two conflicting accounts of what took place. One was provided by the examining doctor in response to my enquiries. There is no contemporaneous written note to support that account. The other account was provided by the social worker, who confirmed in court proceedings in November 2024 that Mss B was asked to remove her clothes entirely. On balance of probabilities, I consider it more likely than not that Miss B was asked to remove her clothes entirely, albeit I accept the Trust’s position that no specific genital examination was conducted.
47. Based on the limited information available to me, I am unable to say whether Miss B became upset during the examination and, if so, to what extent. However, I note the Trust’s position that neither the examining doctor nor the doctor who was acting as a chaperone felt it was necessary to interrupt or halt the examination. This appears to have been in keeping with the social worker’s recollection that Miss B was “shocked” rather than upset at that stage.
48. Nevertheless, the evidence shows that the failure of the Trust and Council to provide clear information to Mrs X and Miss B caused them distress and uncertainty in relation to the examination process as a whole.

Complaint handling

49. Mrs X complained that neither the Council nor the Trust took responsibility for what went wrong in the examination. Instead, she said they simply blamed each other in response to her complaints.
50. In its complaint responses, the Council said the social worker had spoken to Mrs X about the examination in advance but had not been aware Miss B would have to undress. The Council apologised that this had only became apparent during the examination. However, it said “[t]here is also a sense in which we believe that the Doctor had responsibility for explaining to you and [Miss B] what format the examination was going to take.”
51. In the Trust’s response, it said the social worker would usually tell the parent or guardian what will happen during the examination. The Trust said a further conversation would then happen at the hospital. The Trust said the examining doctor had made clear that she would need to check Miss B’s skin for other signs of injury.
52. While these responses are not directly contradictory, it is understandable Mrs X felt the Trust and Council were blaming each other for any confusion.
53. The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the ‘Complaints Regulations’) place a duty on health and social care organisations to investigate complaints properly and in a way that will resolve them efficiently. There is also a duty to cooperate when a complaint is made to one organisation and contains material relevant to the other.
54. The Complaints Regulations say that the organisations must “co-operate for the purpose of (a) coordinating the handling of the complaint; and (b) ensuring that the complainant receives a coordinated response to the complaint.”
55. As I have explained above, the evidence suggests there was confusion surrounding the examination, what this would entail, and what information was shared with Mrs X and Miss B about this process. This was exacerbated as the Trust and Council did not work together to provide Mrs X with a joint response to her complaint as required by the Complaints Regulations. This was fault and added to Mrs X’s frustration and uncertainty.

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Action

56. Within one month of my final decision statement, the Council and Trust will write a joint letter to Mrs X apologising for the distress and uncertainty caused to her and Miss B by their shared failure to:

• provide them with clear information about the child protection medical examination and obtain Mrs X’s informed consent for this process in accordance with the RCPCH Guidance;
• keep accurate records of discussions held with Mrs X about the medical examination process and what this would entail; and
• provide a joint response to her complaint in accordance with the Complaints Regulations.

57. The Council and Trust will each pay Mrs X £100 (£200 between the organisations). This recognises the impact of these events on Mrs X.
58. The Council and Trust will also each pay Miss B £100 (£200 between the two organisations). This recognises the impact of these events on Miss B. The Council and Trust should pay this money to Mrs X to be used in Miss B’s best interests.
59. Within three months of my final decision statement, the Council and Trust will write a joint letter to the Ombudsmen explaining what action they will take to:

• ensure local policies and procedures provide clear guidance for relevant professionals on the child protection medical examination process. This should include guidance on:
1. the need to provide clear information to children and parents/guardians about what the examination will entail;
2. the need to maintain clear records of key discussions with children, parents/guardians, and partner agencies;
3. the need to obtain informed written consent from the parent or guardian of the child.
• ensure relevant staff are familiar with the provisions of the Complaints Regulations, including the duty to cooperate with partner agencies for the purposes of providing a coordinated response to a complaint where appropriate.

60. The Council and Trust will provide us with evidence they have complied with the above actions.

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Decision

61. I found fault by the Council and Trust causing injustice to Mrs X and Miss B. The Council and Trust have agreed actions to remedy this injustice.

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Investigator's decision on behalf of the Ombudsman