What do complaints teach us about end of life care?

See our latest report on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.

Luton Borough Council (25 008 696)

Category : Children's care services > Fostering

Decision : Upheld

Decision date : 23 Jun 2026

The Ombudsman's final decision:

Summary: The Council was at fault for failing to carry out a risk assessment after Mrs X raised safeguarding concerns about transporting her foster children. However, this did not cause Mrs X a significant injustice. The Council was not at fault for failing to listen to the voice of the children as there are records to show it did this. The Council also provided appropriate support to assist with the family’s needs, so it was not at fault.

The complaint

  1. Mrs X complained the Council:
      1. Committed multiple data breaches which resulted in A & B’s birth family knowing personal information about Mr & Mrs X;
      2. Submitted a transition plan, which they had concerns about, to court without Mr & Mrs X’s input;
      3. Failed to move A & B to a new school after leaving Mr & Mrs X’s care which impacted the emotional well-being of Mr & Mrs X’s other children;
      4. Failed to provide the appropriate support to assist with the complex trauma and behaviour’s A & B were exhibiting;
      5. Failed to risk assess in relation to transporting the children;
      6. Failed to listen to A & B’s voices when it came to having contact with the grandparents; and
      7. Failed to ensure the property where the grandparents were residing and meeting A & B, met the minimum health and safety standards for fostering. For example, Mrs X raised the windows did not have safety catches on them and one of the children could have fallen out of them.
  2. Mrs X said this caused her distress, frustration and uncertainty.

Back to top

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 significant injustice, or that could cause injustice to others in future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  2. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide:
    • any fault has not caused injustice to the person who complained; or
    • any injustice is not significant enough to justify our involvement; or
    • there is another body better placed to consider this complaint.
  3. (Local Government Act 1974, section 24A(6), as amended, section 34(B))
  4. We normally expect someone to refer the matter to the Information Commissioner’s Office (ICO) if they have a complaint about data protection. However, we may decide to investigate if we think there are good reasons. (Local Government Act 1974, section 24A(6), as amended)
  5. We cannot investigate a complaint about the start of court action or what happened in court. (Local Government Act 1974, Schedule 5/5A, paragraph 1/3, as amended)
  6. 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)
  7. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).

Back to top

What I have and have not investigated

  1. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended).
  2. Some of Mrs X’s complaint is late. Mrs X complained the Council did not tell her about the children’s cultural needs prior to the placement and raised concerns about the suitability of the match. The case records show that by the end of October 2022, Mrs X was aware of the children’s cultural needs but did not complain to us about it until July 2025.
  3. Mrs X complained the Council did not support her in relation to concerns she raised about one of the children and gender incongruence. The case records show that she raised to the Council that she did not feel supported with this in September 2023 but did not complaint to us until July 2025.
  4. There is no evidence Mrs X could not have complained to us earlier about events before July 2024 and no good reasons to exercise discretion to go back further than 12 months. Therefore, I have investigated from July 2024.

Back to top

How I considered this complaint

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

Back to top

What I found

Relevant law and guidance

  1. Family Courts can make Care Orders which place children in the care of a council because of concerns about the adequacy of the parents’ care causing significant harm to the child.
  2. Councils have statutory duties to children in care to promote and safeguard their welfare. The ‘Care, Planning and Case Review (England) Regulations 2010’ and guidance sets out how councils should manage and arrange placements.
  3. It is normally advised that children do not change schools when moving to new foster placements, wherever possible.
  4. When children are in foster care, the foster carers will have their own fostering social worker, who is responsible for supporting and assessing their care. The children will have their own social worker. Both social workers should work closely together

What happened

  1. Mrs X and her husband Mr X fostered two children, A & B from 2022. There were on-going court proceedings for A & B to eventually transition to their grandparents’ care.
  2. There is a supervision record from July 2024 where the supervising social worker explored virtual contact between the grandparents and the children. The social worker documented the children’s views. One of the children said they didn’t like seeing their grandparents virtually. The other said they liked seeing them.
  3. There is a supervision record from September 2024 where the supervising social worker explored in person contact. One of the children said they were looking forward to in person contact with their grandparents. The other child said they did not know how they felt about in person contact.
  4. Mrs X has provided extracts of emails from September and October 2024 where she notified the Council of A & B’s distressing behaviour such as screaming, hitting and biting.
  5. Mrs X has provided records from October 2024 which show she raised concerns with the Council about A & B taking their seatbelts off in the car, trying to leave the vehicle and exhibiting signs of distress. Mrs X said they would do the following:
    • Fit an in-car camera to keep an eye on the children;
    • Make sure the car doors are locked at all times; and
    • Consider whether two adults are required when transporting the children to and from contact with the grandparents.
  6. Mrs and Mr X stopped fostering the children in November 2024 and they moved to another foster family.
  7. In March 2025, Mrs X made a complaint about the Council’s handling of matters whilst they were the foster carers for A & B. Mrs X said the Council did the following:
      1. Committed multiple data breaches which resulted in A & B’s birth family knowing personal information about Mr & Mrs X;
      2. Submitted a transition plan, which they had concerns about, to court without Mr & Mrs X’s input;
      3. Failed to move A & B to a new school after leaving Mr & Mrs X’s care which impacted the emotional well-being of Mr & Mrs X’s other children;
      4. Failed to provide the appropriate support to assist with the complex trauma and behaviour’s A & B were exhibiting;
      5. Failed to risk assess in relation to transporting the children;
      6. Failed to listen to A & B’s voices when it came to having contact with the grandparents; and
      7. Failed to ensure the property where the grandparents were residing and meeting A & B, met the minimum health and safety standards for fostering. For example, Mrs X raised the windows did not have safety catches on them and one of the children could have fallen out of them.
  8. The Council in its complaint responses said the following:
    • In relation to complaint point C, the Council said there was a collective agreement amongst professionals that when A & B moved from their care it would be important for them to continue to have stability in the school they attended and this was usual for any child who experienced a move between families;
    • In relation to complaint point D, the Council said it offered support to Mr and Mrs X and the children from a specialist mental health clinic;
    • In relation to complaint points B, E and F, the Council said the transition plan to the grandparents was shared with Mrs X and she was happy with the plan. It also said there were differing views about the success of family time/transitions and the triggers for the children’s responses where they did indicate distress. Therefore, it made the decision to place the children with alternative foster carers in order for the children’s care plan to move forwards.
  9. Mrs X remained dissatisfied with the matter and complained to us.

Council’s response to our enquiries

  1. The Council said this case was a highly complex placement involving children with significant trauma histories and elevated behavioural needs. Multiple professionals were involved, including the supervising social worker (SSW), children’s social workers, therapeutic providers, and education professionals.
  2. The Council has provided evidence that it provided support to the children from a specialist mental health clinic. It accepted that Mrs X did not always agree with the support and guidance offered.
  3. The Council said its decision to maintain the children’s existing school placements was guided by the statutory principle of minimising educational disruption, the children’s established attachments to trusted school staff, the need to provide stability following significant emotional and placement upheaval, and the school’s capacity to meet their educational needs.

My findings

Complaint A

  1. Mrs X complained the Council committed multiple data breaches which resulted in A & B’s birth family knowing personal information about Mr & Mrs X. The Information Commissioner’s Office (ICO) investigates complaints about data handling, so I have not investigated this part of the complaint. The ICO is best placed to consider complaints about a public authorities’ failure to follow data protection legislation.

Complaint B

  1. Mrs X complained the Council submitted a transition plan, which they had concerns about, to court without Mr & Mrs X’s input. The court has already considered the transition plan. We cannot look at complaints about what has happened in court. This includes documents written by social workers or other officers for court proceedings. Therefore, I have not investigated this part of the complaint.

Complaint C

  1. Mrs X complained the Council failed to move A & B to a new school after leaving Mr & Mrs X’s care which impacted the emotional well-being of Mr & Mrs X’s other children. The Council explained why it did not move A & B to a new school. The reasons included to not cause the children anymore instability and to reduce educational disruption. The relevant law and guidance encourages Council’s to not change schools for children when moving to new foster placements, wherever possible. Therefore, the Council’s decision was in line with relevant law and guidance and it was not at fault for its decision to maintain the school placement for A & B.

Complaint D

  1. Mrs X complained the Council failed to provide the appropriate support to assist with the complex trauma and behaviour’s A & B were exhibiting. The Council has provided evidence there was support in place from an organisation specifically tailored to assist with families in the situation they were in. Therefore, the Council was not at fault.

Complaint E

  1. Mrs X raised to the Council her concerns around transporting the children to and from contact. This included concerns about them taking their seat belts off and attempting to open the doors. The Council has been unable to provide any evidence it had considered her concerns and produced a risk assessment which was fault.
  2. However, I do not consider this has caused Mrs X or the children a significant injustice as Mrs X sent the Council a detailed email informing it how they would keep the children safe in the car. It is unlikely the Council could have added anything more to this. There is also no evidence the children came to any harm despite Mrs X’s concerns.

Complaint F

  1. Mrs X complained the Council failed to listen to A & B’s voices when it came to having contact with their grandparents. The Council was not at fault as it has provided records from July and September where the supervising social worker has captured the children’s feelings in relation to contact with their grandparents. Whilst the records show there were some positive and negative feelings, this was to be expected as the children lived with Mr and Mrs X for over two years.

Complaint G

  1. Mrs X complained the Council failed to ensure the property where the grandparents were residing and meeting A & B, met the minimum health and safety standards for fostering. The Council cannot control where the grandparents choose to reside. The Council could have decided for the grandparents to meet A & B somewhere else but there are no records to suggest any harm came to the children by meeting the grandparents there.
  2. Whilst Mrs X has raised one of the children could have fallen out of the window, this is a hypothetical injustice. I have not investigated this part of the complaint as any fault has not caused an injustice to Mrs X or the children.

Back to top

Action

  1. Within one month of the final decision, the Council has agreed to provide guidance to relevant officers that safeguarding concerns raised by foster carers should be considered and risk assessed.
  2. The Council should provide us with evidence it has complied with the above actions.

Back to top

Decision

  1. I find fault not causing injustice. The Council has agreed actions to remedy injustice.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page

LGO logogram

Review your privacy settings

Required cookies

These cookies enable the website to function properly. You can only disable these by changing your browser preferences, but this will affect how the website performs.

View required cookies

Analytical cookies

Google Analytics cookies help us improve the performance of the website by understanding how visitors use the site.
We recommend you set these 'ON'.

View analytical cookies

In using Google Analytics, we do not collect or store personal information that could identify you (for example your name or address). We do not allow Google to use or share our analytics data. Google has developed a tool to help you opt out of Google Analytics cookies.

Privacy settings