Summary: Mr X complained about how the Council considered concerns about his son, Y. He said the Council had access to evidence from multiple medical professionals saying there was no medical evidence to support the suspicion of abuse, but it continued to take child protection action. Mr X said this distressed him and his family. There was fault in the way the Council produced reports and assessments using incorrect information and its complaint handling was poor. This frustrated and distressed Mr X and his family. The Council agreed to apologise, make a financial payment, place a letter on the children’s case file and send it to other professionals, and create an action plan to quality assure its assessments.

The complaint

1. Mr X complained about how the Council considered concerns about his son, Y. He said the Council had access to evidence from multiple medical professionals saying there was no medical evidence to support the suspicion of abuse, but it continued to take child protection action. Mr X said this distressed him and his family.

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The Ombudsman’s role and powers

2. 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)
3. If we are satisfied with a Council’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)
4. 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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How I considered this complaint

5. I read Mr X’s complaint and spoke to him about it on the phone.
6. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance.
7. Mr X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Background information

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 have a duty to make enquiries where a child is considered to be suffering or likely to suffer significant harm (the term used in the Act). The enquiries must establish the child’s situation and to determine whether protective action is required. Significant harm covers the risk of physical, sexual and emotional abuse or neglect. (Children Act 1989, section 47)
11. 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’.
12. 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.
13. 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.

14. 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”.
15. 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.
16. 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.
17. 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.
18. The Child Protection Conference is a multi-agency body and is not in itself a body in the Ombudsman's jurisdiction.
19. 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.
20. The Council’s complaint policy says it would respond to a stage one complaint within 10 working days and a stage two within 20 working days.

What happened

21. This is a summary of events, outlining key facts and does not cover everything that has occurred in this case.
22. Y’s mother, Mrs X, took them to the doctor in May 2024. Y had lesions in a private area. The family agreed to seek the advice of a paediatrician. The GP reported this to the Council as a safeguarding concern on the telephone and then sent a formal referral.
23. The Council noted the telephone call on its care notes. It noted the GP said “it is unusual to happen at this age group, and commented it could happen via sexual activity”.
24. The GP’s written referral stated there was a risk of sexual abuse and Y needed “to be assessed fully by a specialist to rule out sexual abuse”.
25. Three days later, the Council recorded the contact on a separate document. The document gave a statement to say Y had lesions which “were” a sexually transmitted infection. The Council noted the family had seen a private paediatrician, who raised no concerns but referred Y to a dermatologist to confirm a diagnosis.
26. Y then saw a private dermatologist. The dermatologist gave a “suggestive” diagnosis of a common viral infection at an appointment three days later.
27. At the end of May 2024, the Council spoke to the private paediatrician. The doctor said they sent the report to Y’s GP but would need the opinion of the dermatologist. The Council expressed concern there was no definitive medical diagnosis. The Council decided to progress the case to a strategy meeting.
28. The Council held the strategy meeting two days later. The report stated the lesions were a sexually transmitted disease. The meeting recorded the private doctors had not shared their views in writing and needed a further appointment. The Council decided to have another strategy meeting, with the attendance and reports from medical professionals.
29. The Council held a second strategy meeting at the start of June 2024. The minutes noted the lesions “are” a sexually transmitted infection. The Council recorded the information from the private medical professionals did not highlight if there was a safeguarding concern or not. The Council said an NHS medical professional would need to see Y. The private medical professionals in the meeting said they did not know about the safeguarding concerns and would not comment on these matters. All professionals in the meeting decided the case met the threshold for a section 47 investigation and a child protection medical was needed.
30. The Council referred Y for a child protection medical the following day. The service declined the referral. It said there was no evidence of sexual abuse. The service recommended further direct work with Y and their siblings.
31. The Council visited Y and the siblings a week later. Y did not raise any concerns, but their sibling did raise a separate concern. The Council completed the assessment for the family.
32. The following day the Council decided to hold a child protection conference. It recorded this was because of the sexual abuse concerns, and Y’s siblings’ disclosure.
33. The Council held the child protection conference two days later. The minutes noted the lesions “could” be a sexually transmitted infection. Most professionals said the threshold was not met for a child protection plan as there was no evidence of sexual abuse and there was no formal diagnosis. The Council decided it would offer support to the family under a child in need plan.
34. At the end of June 2024, the NHS considered the case and detailed it did not have safeguarding concerns. The family sent the report to the Council.
35. The Council visited the family home. Mr X asked the Council to amend the reports because they contained factual inaccuracies.
36. In August 2024, the Council recorded Mr and Mrs X did not consent to working with the family under a child in need plan.
37. The Council closed the case in September 2024.
38. Mr X complained to the Council in December 2024. He complained the records and reports contained errors and the Council did not arrange for an NHS doctor to see Y. The Council spoke to Mr X to confirm the complaint in January 2025.
39. The Council responded to the complaint in March 2025. The Council said it could not fully investigate because Mr X did not consent to the Council discussing the matter with other professionals. The Council accepted grammatical errors in the assessment and apologised, but said there were no inaccuracies. The Council said it acted in line with its statutory responsibilities.
40. Mr X asked the Council to escalate the complaint to stage two at the end of March 2025. He said the Council mishandled the safeguarding. He said the Council made misleading statements.
41. The Council issued its stage two response at the end of May 2025. The response said it was difficult to reach a conclusion because Mr X withdrew consent to discuss the concerns. The Council acknowledged grammatical errors in the assessment and would send the amended version. Mr X asked to meet with the Council.
42. Mr and Mrs X met with the Council in June 2025. During the meeting the Council acknowledged delays in its complaint handling. The Council said the assessment “reworded something that was not there” and it should have quoted what the GP said. The Council accepted it should have reviewed the reports before it issued them.
43. Mr X was not satisfied with the Council’s response and has asked the Ombudsman to investigate. Mr X would like the Council to apologise, make a financial payment and write a letter to other professionals explaining the situation.
44. In response to my enquiries the Council stated the GP made the initial referral on the telephone, then a written referral. The Council said they differed slightly, but both raised concerns of risk of sexual abuse. The Council said it made decisions regarding possible sexual abuse and the concerns raised by Y’s sibling.

My findings

Safeguarding concerns

45. The focus of the Council should always be the well-being of the child. The Ombudsman recognises safeguarding procedures can be stressful, but the Council has a duty to investigate concerns.
46. This is a complex and emotive case. The Council has provided evidence of a case note of the telephone referral and the written referral from the GP. The Council is correct to say they differ. The case note of the telephone call notes it was unusual for a child to have lesions and it could happen via sexual activity. The written referral said there was a risk of sexual abuse and Y needed to be assessed by a specialist to rule out sexual abuse. At no point in the case recording or the written referral did it say Y “had” a sexually transmitted infection. The Council wrote this in a document three days after the referral, and in subsequent reports and assessments. This is not an accurate reflection of the referral. This is fault.
47. The Council would still have considered if there was a risk of sexual abuse. This is what the referral was for. The Council would still have completed the safeguarding enquiries. The professionals attending the strategy meetings considered all the information presented and decided the Council should conduct a safeguarding investigation. The Council conducted a home visit where Y’s sibling raised a safeguarding concern. The Council decided to progress the case to a child protection conference.
48. The professionals attending the child protection conference considered all the information presented. I note Mr X provided private medical information on this matter. The Council, and other agencies involved, considered the information but wanted an NHS opinion. This would provide a detailed response and give an independent medical opinion on child protection concerns. The professionals are entitled to gather further information and to request this. The professionals decided to support the family through a child in need plan, and the case did not warrant a child protection plan. A child in need plan is voluntary. The family decided they did not want to engage with the child in need plan and the Council closed the case.
49. The Council has made multi-agency decisions throughout the case. I cannot comment on the decisions taken in multi-agency meetings. I cannot say the outcome would have been different had the Council provided accurate information in its reports and assessments to multi-agency meetings and other professionals. However, the Council’s initial fault has caused distress and uncertainty. It has caused Mr and Mrs X to ask if it would have been different and if they did not need to go through the distressing process.

Complaint handling

50. The Council complaint policy, detailed in paragraph 20, confirms the Council would respond to a stage one complaint within 10 working days and stage two within 20 working days.
51. Mr X complained to the Council in December 2024. The Council issued its response in March 2025, a 44 working day delay. This is fault, frustrating Mr X.
52. Mr X asked for a stage two investigation in March 2025. The Council responded at the end of May 2025, a 21 working day delay. This is fault, frustrating Mr X.

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Agreed action

53. To remedy the outstanding injustice caused to Mr X by the fault I have identified, the Council agreed to take the following action within 4 weeks of my final decision:
• Apologise to Mr X for the distress and uncertainty caused by inaccurately recording the referral and delayed complaint responses. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
• Pay Mr X £500 to recognise the distress and uncertainty the Council fault caused.
• Write a letter, to share with Mr X and to place on the children’s case files, accepting and detailing the errors in the Council reports and assessments. Specifically, the referral from the GP did not say Y “had” a sexually transmitted infection.
• Send the letter to any professionals the Council sent the incorrect reports and assessments to.
• Produce a plan on how the Council will quality assure assessments to ensure they are an accurate reflection of the concerns raised and ensure they are suitably monitored.
• Share a copy of this decision with staff in the relevant departments to consider the lessons that can be learned from this case.
54. The Council should provide us with evidence it has complied with the above actions.

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Decision

55. I have completed my investigation. I have found fault by the Council, which caused injustice to Mr X and his family.

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Investigator's decision on behalf of the Ombudsman