Peterborough City Council (17 019 369)

Category : Children's care services > Disabled children

Decision : Upheld

Decision date : 25 Sep 2018

The Ombudsman's final decision:

Summary: Mrs C complained that the Council failed to carry out a specialist assessment for her son, D, as a deafblind child, or provide appropriate services for him over a four year period. This failure had a devastating impact on the whole family and led to Mrs C asking for her son to be taken into care. The Council has agreed to pay Mrs C and her family a total of £12,750 and review its procedures in respect of other deafblind children in its area.

The complaint

  1. Mrs C complains that Peterborough City Council (the Council) failed to properly assess her son, D, as a deafblind child and provide appropriate services for him. The Council’s stage three complaints Panel upheld twelve out of thirteen of her complaints and recommended an immediate specialist assessment along with reasonable compensation. Mrs C complains that the Council has failed to implement these recommendations: the assessment is still outstanding and the Council has only offered her £150 compensation. She incurred legal costs in pursuing her complaint and paid significant amounts of money to provide services for D. Her other two children were also affected negatively by the lack of specialist support for D.

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The Ombudsman’s role and powers

  1. 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)
  2. 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)

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How I considered this complaint

  1. I have considered the complaint and the documents provided by the complainant, made enquiries of the Council and considered the comments and documents the Council provided. I have written to Mrs C and the Council with my draft decision and considered their comments.
  2. 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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What I found

  1. This guidance came into force in April 2015. Local authorities must follow the guidance unless they can demonstrate legally sound reasons for not doing so. It requires local authorities to:
    • identify, make contact with and keep a record of all Deafblind people in their catchment area (including those people who have multiple disabilities which include dual sensory impairment);
    • ensure that when an assessment of needs for care and support is carried out, this is done by a person or team that has specific training and expertise relating to Deafblind persons - in particular to assess the need for communication, one-to-one human contact, social interaction and emotional wellbeing, support with mobility assistive technology and habilitation/rehabilitation;
    • ensure services provided to Deafblind people are appropriate, recognising that they may not necessarily be able to benefit from mainstream services or those services aimed primarily at blind people or deaf people who are able to rely on their other senses;
    • ensure that Deafblind people are able to access specifically-trained one-to-one support workers if they are assessed as requiring one;
    • provide information and advice in ways which are accessible to Deafblind people; and
    • ensure that a Director-level member of the local authority senior team has overall responsibility for Deafblind services.
  2. The preceding guidance from 2009 was substantially the same in terms of the requirement to identify, assess and provide services.

What happened

  1. Mrs C’s son, D, is deafblind (he is profoundly deaf with a central visual impairment). He also has learning disabilities and challenging behaviour. He was born in 2010 and diagnosed as profoundly deaf at the age of two weeks. The Council provided hearing impairment support at that time. He was diagnosed with a visual impairment at six months and the Council provided visual impairment support from 18 months.
  2. D lived at home with his parents and siblings, one of whom also had a medical condition requiring extra support. D attended a specialist school and was receiving additional support from a respite centre for children with disabilities.
  3. In April 2014 the Council received a referral requesting respite care for D. The Council completed an assessment but concluded it had no role in providing services. In November 2014 the family contacted the Council to ask for direct payments to support care on Sundays but the Council declined to carry out an assessment.
  4. In April 2015 D’s consultant requested behaviour home support for D and in June 2015 made a further request for an assessment. The consultant expressed concern about the high level of care D required and the significant impact on the family. Around this time Mrs C contacted the Council’s out-of-hours service because D’s behaviour had deteriorated significantly: he was harming himself and disturbing the family.
  5. In September 2015 the Council completed a children and families assessment. It found that there were nine professionals involved in completing assessments, developing plans and monitoring D’s development. Following the assessment, direct payments started in December 2015 for Mrs C to arrange support at home for D. The direct payments were increased in March 2016 due to D’s increasing needs and the negative impact on the family.
  6. In April 2016 D’s consultant raised concerns about the level of supervision D needed and requested the care package be reviewed. The consultant considered D needed one-to-one adult supervision at all times and it was really challenging for Mrs C who had other siblings to care for. D was trying to eat glass at that time, banging his head frequently, not sleeping and being very distressed throughout the night.
  7. The school also stated the family was very distressed and the school was concerned about their capacity to support D at home without further help. D’s behaviour was affecting his siblings. The Council agreed to fund transport to a breakfast club and within a month D’s behaviour had improved significantly. However, the Council withdrew funding for this in June 2016 saying it did not have a budget to provide it.
  8. In May 2016 the mental health service said that D needed a more comprehensive behaviour assessment. It considered D might be sensory seeking and an occupational therapy assessment might provide more information. The Council considered D wearing a helmet to reduce damage from head-banging but discounted this as unworkable and said it would not solve the situation at home.
  9. In June 2016 Mrs C told the Council she could not keep the children safe or meet D’s needs. SENSE, the national charity supporting people with complex communication needs, told the Council that D was entitled to a specialist multi-sensory impairment (MSI) assessment. Later that month the Council agreed to additional overnight short breaks at the respite centre along with more day-care and increased direct payments during the holidays.
  10. In July 2016 D started to receive medication to calm him. Initially his behaviour improved but once he returned to school his destructive behaviour returned.
  11. In September 2016 a national charity supporting children and young adults with learning disabilities and additional communication needs (“the Charity”), carried out a speech and a language assessment and offered some advice. It recommended a full and comprehensive assessment of D’s sensory needs by a specialist occupational therapist and a further assessment of his visual skills.
  12. Mrs C said she felt this was the first time professionals had focussed on D’s needs and tried to identify why he behaves in the way he does. She said he needed to be cared for using an MSI approach.
  13. In December 2016 Mrs C raised concerns that she had not received training to manage or handle D. The social worker said there was no-one willing or able to provide this training. The Council discussed the possibility of exploring training but nothing came of it.
  14. Around this time the Council provided a safe space, (recommended by an occupational therapist) to help keep D safe at night. But the situation exacerbated D’s behaviour and he increased self-harming while in the space.
  15. In January 2017 SENSE once again requested a specialist MSI assessment. The Council recommended a further five hours’ domiciliary support but could find no providers who had the capacity or skills to support D.
  16. In March 2017 D’s behaviour deteriorated further. The school and the respite centre reported an increase in aggressive and destructive behaviour and said he needed one-to-one support at all times. He had injured staff and Mrs C. The Council said the expectation on the family was unrealistic. It accepted that Mrs C could not cope with meeting D’s needs and those of the other siblings. The Council suggested shared care. Mrs C said she was willing to consider shared care or a permanent care arrangement.
  17. In April 2017 the children’s services team considered that a residential school with a specialist MSI approach was the best option for D, rather than the current piecemeal approach of multiple care-givers, causing stress to D and the whole family. It noted that if the situation continued, the Council would need to double the direct payments to provide two-to-one support in accordance with the current risk assessment.
  18. A Joint Agency Support Panel [JASP] met on 24 April 2017. This consisted of staff from health, social care and education. Its purpose was to consider resources and what is best for the child. The social workers involved presented D’s case and said a shared care arrangement would be the best for D. It would prevent the breakdown of the current piecemeal arrangements leading to D becoming permanently looked after by the Council. They considered the residential placement would ideally be time-limited with the hope he could return to the community.
  19. The Chair of the Panel was concerned about the long-term cost of a residential care placement and felt that the best place for most seven-year-old children was in a family setting. He was concerned that a residential placement was likely to promote institutionalisation and create attachment issues.
  20. The Panel rejected the residential care option and recommended:
    • Increased time at the respite centre;
    • The social worker approach local charities for support;
    • The social worker should consider a family group conference;
    • SENSE provide services; and
    • Foster care be pursued.
  21. D’s consultant expressed disappointment with the decision and Mrs C complained that the Council was failing to meet D’s needs. The Chair of the Panel responded to Mrs C saying that the Panel’s greatest concern was to develop a support plan that would avoid D being placed in residential provision, including the possibility of foster care. D’s school also said it considered that a residential package would best meet D’s needs and those of his family.
  22. In respect of the recommended options:
    • The respite centre could not offer any more hours or the required two-to-one support. Neither could it offer trained staff to meet D’s MSI needs and challenging behaviour.
    • The social workers had tried before the Panel meeting to find suitable specialist providers but without success. The Council was already using a large number of agencies using multiple carers creating a lack of continuity and stability for D. When workers were injured they refused to go back, some providers required two-to-one support and no provider had suitably trained specialist staff.
    • The assessment carried out in 2015 identified that Mrs C had limited family support: there were no paternal grandparents and her family lived in a different city some distance away and could not provide long term care for D.
    • SENSE had recently restructured and could no longer provide specialist support. Furthermore the Council had not acted on SENSE’s previous suggestion to carry out a MSI assessment.
    • Foster care had already been explored, including an overnight trial with an experienced foster carer who knew D well, but no suitably trained carers could be found who could keep D safe at home.
  23. In May 2017 Mrs C again said she had no training on how to handle or manage D. She was paying privately for a childminder of one of D’s siblings as she was on her own with all three of them.
  24. At the beginning of June, Mr C reported that D was beyond their control, everyone was upset and their other son had burnt himself while Mrs C’s attention had been focussed on D. He felt the situation could not continue, as there were no viable options for support at home. Shortly after this Mrs C asked the Council to look after D as she and the family could no longer look after him.
  25. D became a looked after child under section 20 of the Children Act. The Council placed D at the respite centre while a longer-term placement was sought. Initially the Council considered foster care before a residential placement, but could not find suitable carers.
  26. At his first review, the Council identified that D’s needs were not being met; specifically he had no formal communication system, his MSI communication needs were not being met and none of the recommendations made by the Charity in September 2015 had been implemented.


  1. In June 2017 Mrs C instructed a solicitor and made a formal complaint, comprising 13 separate complaints. The Council appointed an investigating officer and independent person to carry out an investigation at stage two of the statutory children’s complaints procedure. They produced a report in November 2017 upholding five complaints in full, four in part and making no finding on three. The upheld complaints included the following:
    • The JASP failed to understand D’s unique and complex needs and failed to understand that the Council had tried and exhausted all the suggested options. It had repeatedly searched for providers and support but failed due to a lack of suitably qualified staff able to meet D’s MSI needs. residential care as recommended by D’s social workers was the only realistic option.
    • The Council failed to carry out assessments to consider the changing circumstances of the family and the reported impact on the siblings. It failed to carry out a carer’s assessment or update the children and families assessment.
    • The Council had failed for over a year to carry out an MSI assessment, despite it being a legal requirement to do so. This had resulted in D’s needs not being properly addressed. Although the Council said it was difficult to find suitably qualified/trained assessors, it was not clear why the Council had not done the assessment.
    • The Council failed to offer Mrs C an appeal against the JASP decision.
  2. Mrs C went to the stage three review panel in February 2018. The Panel upheld a further three complaints in full, meaning that in total twelve of her thirteen complaints had been upheld in full or in part. The Panel found that it was very unlikely that the new legislation relating to MSI assessments had been followed in properly assessing D and identifying his needs. It said D’s case was difficult and complex and..:

“D’s very complex needs did not fit into ‘normal’ procedures and placements; there was no holistic approach and he was badly let down. His special needs and what was best for him could have been identified much earlier- perhaps just a few months after his birth”.

  1. The Panel recommended that:
    • The Chief Executive of the Council send a full and unreserved apology to Mrs C;
    • The procedure for JASPs be amended to ensure decisions are sent to the parents and they are advised of their appeal rights;
    • There should be a full audit of the case which will lead to faults being identified and then training should be developed for social workers for the future;
    • The case should be brought to the attention of OFSTED;
    • The policy regarding deafblind children and adults is reviewed/re-written within three months and recommendations put into effect within six months.
    • The Council should identify and contact other local authorities who have already successfully implemented the legislation to learn from them in developing good practice for deafblind children and adults.
    • An MSI assessment should be undertaken as soon as possible by a suitably qualified person in line with the statutory guidance.
    • The Council should pay Mrs C a reasonable sum in compensation for the stress and anxiety she and her family have been caused; the failings in offering the support D needed when he needed it and the money the family had to pay in excess of their direct payments to support D.
  2. The Council wrote to Mrs C in March 2018 regarding the Panel’s finding and recommendations. It said it agreed with all the recommendations and asked for an action plan to be drawn up. It apologised to her. It said it would consider compensation once the MSI assessment had been done to consider if more care and support should have been given. It offered £150 in respect of her time and trouble in making the complaint. It declined to pay her legal costs as it did not consider legal representation was necessary.
  3. In response to my enquiries, the Council provided a copy of the action plan drawn up following the stage three review panel. It says it has agreed with Mrs C to refund the costs she incurred on top of the direct payments once she provides evidence.

Current situation

  1. Mrs C then complained to the Ombudsman. She said D started a 52-week residential placement at a school run by the Charity in October 2017. It is a school for young people with complex learning disabilities and significant communication difficulties. They have a number of MSI trained staff. D receives two-to-one care but only part of that is funded by the Council. He has made significant improvements since being there. He comes home every six weeks for two nights and his family visits him weekly.

MSI assessment

  1. This was due to take place in May 2018 but was postponed when Mrs C queried whether a suitably qualified person was going to do it. It was finally completed in June 2018 and she has recently provided me with a copy of it.
  2. The assessment says that D is one of the most sensory deprived children ever assessed by SENSE. His primary learning need is deafblindness / multi-sensory impairment. D needs specialist input from specially trained staff to develop a highly consistent approach across all domains of life, from school, residential to home. The report recommends a detailed training programme for all people and family involved in D’s care and the provision/training of four Intervenors (a highly trained person to act as the eyes and ears of a deafblind person providing individual support to enable effective communication and the reception of clear information).


  1. Mrs C spent approximately £2000 on a solicitor. Between January and May 2017 she also spent about £1600 on top of the direct payments in employing a teaching assistant to help D on Sundays so Mrs C could attend activities with her other children. Mrs C had to give up her job as a teacher due to the stress of her caring role and particularly her lack of sleep. She started to suffer panic attacks. She takes medication and attends therapy for anxiety and depression. She feels that her other children were significantly affected by D’s disturbing behaviour along with the resulting lack of sleep and attention.


  1. The Council should have carried out an MSI assessment of D at the latest in April 2014 when a referral was made and possibly earlier given that it was aware of D’s deafblindness from 2011. It was asked to carry out an assessment twice more before completing a standard children and families assessment in September 2015 which led to direct payments starting. In early 2016 both D’s doctor and his school raised concerns about the level of support D was receiving. In mid-2016 the mental health service said he needed a comprehensive behaviour assessment and SENSE first requested a specialist MSI assessment. The Charity said in September 2016 that he required a specialist assessment and SENSE asked again in January 2017.
  2. Despite the clear deterioration in D’s behaviour and the devastating impact on the family the Council did not review its own children and families assessment to include the other siblings, neither did it carry out an MSI assessment or a carer’s assessment. It did not carry out an MSI assessment until June 2018, over four years later. It has given no clear reason why it departed from the Government guidance to such a significant degree.
  3. The failure to carry out this specialist assessment meant that the Council did not have sufficient understanding of D’s needs to provide the correct services for him. It persisted in following its mainstream procedures to source providers and carers for D, despite clear evidence that these were not working. It also refused to consider a residential placement even though its own social workers, the school and D’s consultant were recommending this as the best, and only, option for D.
  4. During this period, the family situation broke down to such an extent that Mrs C made the very difficult decision to ask the Council to look after D. After further fruitless searches for foster carers or other providers, D finally started in the residential placement, which the Council so strongly rejected six months’ earlier. He has made significant progress and is now receiving the support he needs.
  5. It is impossible to say what may have happened, had the MSI assessment been done sooner but it is likely that D would have received better and more focussed support at a much earlier point, which is likely to have relieved the significant impact on the rest of the family. Mrs C says it would have helped her enormously if she had been given the early support MSI materials when D was a baby, as it would have explained all the unusual and distressing behaviours she experienced with D, such as not liking to be held or rocked. With specialist training and support for Mrs C and the involvement of Intervenors, D’s behaviour may not have deteriorated so much, and some form of shared care or community placement may have worked.

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Agreed action

  1. The Council offered to refund the costs Mrs C incurred for extra childcare on top of the direct payments and £150 for her time and trouble. I am unclear if the Council intends to consider any further compensation in the light of the MSI assessment but I considered the offer was inadequate for the injustice experienced by Mrs C, D and the rest of the family.
  2. I have considered how this complaint should be remedied in line with the Ombudsman’s guidance. There is evidence of:
    • significant avoidable distress – undue significant stress, inconvenience and frustration for Mrs C in continually trying to get a proper assessment and support for D over a period of at least four years, with the period from March 2016 to June 2017 being particularly difficult;
    • uncertainty - there will always be doubt and regret for Mrs C as to whether the outcome could have been significantly different for everyone if the MSI assessment had been done at an earlier point;
    • risk of harm/actual harm - D hurt himself continually and was referred for an MRI scan to assess the damage to his head. Mrs C was injured by D requiring hospital treatment on at least one occasion and one of his siblings hurt himself while Mrs C was distracted with supporting D. Aside from these specific incidents the impact on the siblings of D’s behaviour over a prolonged period was likely to be harmful and Mrs C developed depression, anxiety and panic attacks.
  3. In recognition of these impacts I asked the Council to pay a total of £12,750 made up as follows:
  • £3450 for solicitor’s fees and teaching assistant;
  • £2000 for D for distress and harm over a prolonged period;
  • £1000 for the distress to the other children;
  • £2000 for the distress to Mrs C of putting D into care;
  • £300 for Mrs C’s time and trouble in pursuing the complaint and the assessment; and
  • £4000 for Mrs C for the impact on her health and loss of her job over the past four years.
  1. I also asked the Council to:
    • provide me and Mrs C with an updated copy of the action plan once the audit and procedural reviews are completed along with copies of any new procedures or training as a result of liaison with other authorities;
    • explain to Mrs C why the Council is not funding two-to-one support in D’s current placement;
    • ensure that it has carried out an MSI assessment in respect of any other deafblind children it has identified in the borough and reviewed its service provision in the light of the assessment.
  2. I am pleased to say the Council agreed to all the recommendations. It says:
    • the audit is complete and the Council is currently working on specific training as a result.
    • the Clinical Commissioning Group (CCG), Education and our Early Support/ Help teams are working together to review its policy/procedures and these will be finalised in October.
    • following discussion with the Charity, it confirmed that staff have been providing two-to-one support: forty additional two-to-one hours are being provided in term time and fifty in school holidays. The level of resource will be kept under review by Social Care, Education and the CCG. The provider considers the current level of support is appropriate to meetthe level of needs.
    • the Council is working closely with the CCG who has a duty to inform the Council of children with MSI. The Council has agreed to develop a register of those known and will then determine who has and has not been assessed and ensure any child identified as not being assessed is offered an MSI assessment. The Council also intends to set out in its Local Offer to parents, information about how it holistically supports children with this level of MSI need.

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Final decision

  1. I consider this is a reasonable and fair way of resolving the complaint and I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman

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