Summary: Miss Y complains about the Council’s failure to safeguard her children when they were placed into short-term foster care under an Interim Care Order. We find some fault by the Council causing injustice to Miss Y and her daughter, D. The Council will pay £500 to Miss Y and undertake the service improvements listed at the end of this statement.

The complaint

1. Miss Y complains about incidents concerning her children whilst they were subject to interim care orders. With reference to her older daughter, D, she says:
1. The Council did not ensure she received the medication she needed for a period of four days;
2. The foster carer then gave her daughter the medication to administer herself, without supervision;
3. A social worker lost the medication and then lied about its whereabouts; and
4. The foster placement was a household containing cats, which her daughter is allergic to.
2. Regarding her youngest daughter, E, Miss Y says:
1. The Council failed to tell her about a possible heart condition which doctors identified whilst the baby was in care. The Council also failed to act upon the hospital discharge letter which required the parent or guardian to make a follow-up appointment; and
2. Miss Y says she only became aware of the problem when she took her daughter for routine immunisations and the GP relayed the notes on their system. As a result, Miss Y says her daughter’s referral was made six weeks later than it should have been.
3. Miss Y also raises concerns about the first allocated social worker, who she says shouted at her and the children, failed to offer support and ignored her daughter’s requests for help.

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The Ombudsman’s role and powers

4. 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)
5. 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(i), as amended)

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How I considered this complaint

6. During my investigation I discussed the complaint with Miss Y and considered any information she provided.
7. I consulted any relevant law and guidance and made enquiries of the Council. I considered the response before making a decision.
8. Miss Y and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
9. 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

What should happen

10. Where a child needs immediate protection, the ‘Working Together to Safeguard Children’ guidance says the council, the police or the NSPCC must act as soon as possible if removal is required. Councils can apply for an Emergency Protection Order (EPO) or the police can issue a Police Protection Order (PPO) which allows the police officer to remove the child immediately. An EPO may take several days to obtain but if granted means the child can be removed.

What happened

Complaint 1a) delay in providing D’s medication

11. On the evening of 12 February 2022, and whilst on holiday in the UK, Miss Y and her partner were involved in an altercation which resulted in their arrest. Consequently, Miss Y’s five children were removed by the police, under a PPO, to a place of safety.
12. The Council’s notes show the four oldest children were placed into emergency foster care in the early hours of 13 February. The youngest child, who was around 12 weeks old at the time, was taken to hospital for medical checks.
13. At around 5am on 13 February, a social worker recorded a note to confirm that one of the children, whom I will call D, has “anti-psychotic medication and sleeping tablets”. The Council noted that it would arrange retrieval of the medication from the family’s holiday accommodation.
14. A few hours later, a social worker called the local hospital to try and get a record of D’s prescribed medication. In the meantime, Miss Y was released from police custody. She called a social worker to say that she would try and get D’s medication in the morning. Miss Y said she did not know what the medication is called, but that it was prescribed by the Children and Adolescent Mental Health Service (CAMHS) and D needs to take 0.2ml each day for the “voices in her head”.
15. The social worker then called D’s foster carer who explained that D had access to her sleeping medication, which she had taken. The foster carer confirmed that D did not have any other medication in her possession, but the police had attended the holiday accommodation on the afternoon of 13 February and were only able to locate an empty bottle. The foster carer confirmed that D was ‘alright’ and did not express any concerns about her wellbeing.
16. The following day Miss Y called the Council again to express concerns about the impact of the missing medication on D.
17. In response to our enquiries, the Council explained the new medication was delivered to D’s foster placement on 15 February. The Council accepts that, due to the children being removed to a place of safety on an emergency basis, D did not have all her belongings. This was unavoidable and not due to fault.
18. The Council says the police were only able to locate an empty medicine bottle in the holiday property. In my view, it therefore follows that, irrespective of D’s placement into emergency foster care, she would have required a new prescription. In which case there would have likely been a 48 hour wait for the medication.
19. Although there was a short period during which D went without her medication, I do not consider this was wholly due to Council fault and I do not uphold this part of the complaint.

Complaint 1b) administration of D’s medication

20. Miss Y complains the foster carer allowed D to administer her own medication. Miss Y says this was not appropriate and that D requires an adult to oversee the provision of her medication.
21. In response to our enquiries, the Council says the foster carer allowed D to self-administer medication because D told her that this is what she does at home. The foster carer told the Council she supervised D whilst she took the medication.
22. The Council’s policy ‘Health of Children in Care: Medication – Storage, Administration and Recording’ contains the following key principles:
• Everyone involved in looking after and administering medicines for other people are responsible for keeping good records.
• The child may be competent to administer their own medication and they may need to be given support to look after their own medicines as appropriate.
• All medication to be kept in original dispensed container with the child’s name and administration instructions.
• The administration of both ‘over the counter’ and prescribed medicines must be recorded on a ‘Medication Record Chart’ provided by the Council.
• All known allergies should be recorded on the medical forms provided.
• Individual records must be kept for each child in care.
23. We cannot ascertain what level of supervision D received whilst taking her medication because there are no records of the administration of her medication. This is not in accordance with the Council’s policy and is fault. Although I am mindful that D’s foster placement was very short term, I consider the fault has caused Miss Y avoidable uncertainty and distress which the Council will remedy with the actions I have listed at the end of this statement.

Complaint 1c) social worker’s loss of medication

24. Miss Y says the first allocated social worker mislaid D’s medication when she returned home, and then lied about its whereabouts. She says this is evident because the social worker said he handed over two bottles of liquid medication, but this cannot be true because one of the bottles contained tablets. Miss Y says this became apparent during a remote review meeting when the social worker exited the meeting to avoid any discussion about the subject.
25. I have considered the case notes to see whether there is any reference to the lost medication. There are no notes of what happened on the day D’s medication went missing. The only information we have is Miss Y’s assertion and a short exert from an undated review by the Council, which states,

“Your mum told us that the [medication] was not returned, and the sleeping tablets were put in your bags [D] which is not appropriate. [Social worker] you told me that you gave it to mum, she said no you did not, you then told me that the carer had shown you the bottle which was empty. [D] your mum said it should not have been, and she has had to order more medication, but it takes time to arrive. [D] I have asked [social worker] to find out where your medication is, and I will alert his team manager regarding the handling of your medication”

26. The Council has confirmed the social worker was employed via an agency and no longer works for the Council. For this reason, the Council says it has not been possible to ascertain what happened to the missing medication. The intervention by the social worker’s manager merely involved a request for the worker to check their car. The Council has no further information to provide.
27. In my view, and on the balance of probabilities, I consider it more likely than not that the social worker lost D’s medication. This caused injustice to both Miss Y and D because Miss Y had to arrange another prescription and meanwhile D went without her medication. The Council will implement the agreed actions we have listed at the end of this statement.

Complaint 1d) exposure to allergy

28. Miss Y says D has an allergy to cats, but despite this she was placed in a household containing cats. Miss Y is not aware of any adverse impact on D during the time she spent in the foster household but remains concerned about the Council placing children into places of safety without first checking whether the child has any known allergies.
29. As paragraph 22 of this statement sets out, the Council is required to list any known allergies on the child’s health information form which is shared with the foster carer. The Council has not been able to provide any such paperwork for D.
30. I appreciate that D’s allergies may not have been known by the Council as soon as she was placed due to Miss Y being in police custody. However, based on the evidence seen, I consider there was a missed opportunity by the Council to gather and record this information as soon as it was able to.
31. I understand this has caused Miss Y some general concern, but I am not persuaded there is any significant injustice to D which the Council should remedy.

Complaint 2a and b) medical assessment of E and follow-up appointment

32. When she was taken into emergency foster care, Miss Y’s baby, E, received a medical examination in hospital. This was following concerns raised by professionals about E’s presentation. During the examination doctors found a possible heart defect and requested that E’s parent or guardian makes a follow-up appointment for further investigation. This information was in the discharge summary letter which Miss Y says was handed to E’s social worker on discharge.
33. Miss Y says this important information was not relayed to her by the Council, either during E’s placement or after she was returned to the family home. Instead, Miss Y says she found out by chance when she took E for some routine immunisations six weeks later. During that appointment Miss Y’s GP mentioned the possible heart defect. Miss Y at first thought the doctor was mistaken and asked them to check the records again. It was at this point Miss Y says she found out about the need to arrange a follow-up appointment for E.
34. In response to our enquiries, the Council said:

“The looked after children paperwork dated 5 April 2022 recorded that [E] had a heart defect at birth which [Miss Y] would have been aware of, [Miss Y] would have been provided with any medical information that the council were in receipt of including the looked after children review paperwork. Any medical information that the council hold in respect of [Miss Y’s] children would have been shared with her at the time and through the looked after children review process”

“The Isle of Wight is aware that the Paediatrician suggested a follow up appointment for [E] in Cardiac outpatients. The discharge summary was sent to [Miss Y’s] GP to make the referral. Children’s social care did not receive a copy of the discharge summary until several weeks after the event”

35. Other than the health assessment completed for E on 5 April 2022, which refers to her birth defect, there is no evidence to show the Council relayed the hospital’s concerns to Miss Y. The Council say the hospital did not share any paperwork with the social worker when E was discharged, and instead this was sent directly from the hospital to E’s registered GP to make the necessary referrals.
36. The notes entered by the social worker say E was, “… comfortable and settled throughout the journey [from hospital] and there had not been any significant concerns from the medical checks that were done with you whilst you were at the hospital”
37. It is not possible to ascertain with certainty what information the hospital relayed to the Council after assessing E. It therefore falls to me to decide this complaint using the balance of probabilities based on the information available.
38. The social worker’s contemporaneous notes recorded on the day of E’s discharge say the hospital had no significant concerns. In my view, I consider it more likely than not that the hospital did not share any detailed information with the social worker otherwise I would expect to see it referenced in the note made on the day. I consider it more likely that the hospital sent the discharge summary letter direct to E’s GP, and this explains why it was mentioned to Miss Y during her visit to the doctor’s surgery. For these reasons, I do not uphold this part of the complaint.

Complaint 3) social worker concerns

39. Miss Y raises a range of concerns about the first allocated social worker, including that he shouted, was not supportive and ignored the family’s requests for help. Upon receiving Miss Y’s complaint, the Council agreed to allocate a different social worker. Miss Y has no concerns about her new social worker.
40. I have already upheld complaint 1c) in respect of the social worker in question because I found, on balance, it was more likely than not that they lost D’s medication in transit. I made this finding based on the available information.
41. However, there are no records available for me to consider regarding the other claims about the social worker’s behaviour and overall professionalism. The available information is further limited because the social worker no longer works for the Council and so we are unable to obtain their comments.
42. We cannot reach a finding on this element of Miss Y’s complaint because there is not enough information for us to analyse in respect of the social worker’s behaviour.

Complaint handling

43. In response to Miss Y’s complaint, the Council said it would not consider her concerns because “… there are current care proceedings in place with your children who are currently subject to an Interim Care Order. As such any concerns that you have regarding the social worker and his involvement with your family can be addressed through the Court process”.
44. The LGSCO took a different view; we decided that Miss Y’s complaint about the Council’s failure to safeguard her children was separable from the matters put before the courts. Miss Y was not disputing the decision to grant a care order, but instead said her children were unnecessarily exposed to risk due to the social worker’s actions. The Council could, and should, have dealt with this separately because the court would not have considered any general concerns about the social worker as part of the care proceedings. Furthermore, the Council did not signpost Miss Y to the LGSCO when it refused to consider her complaint.
45. The Council’s complaint handling caused unnecessary frustration and time and trouble which the Council will remedy with the agreed actions below.

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Agreed action

46. Within four weeks of my final decision, the Council will:
• Apologise to Miss Y for the failure to ensure the correct administration of D’s medication, the subsequent loss of that medication and the failure to deal with her complaint; and
• Pay £500 for the combined uncertainty, distress and time and trouble caused by the faults referred to above.
47. Within eight weeks of my final decision, the Council will also:
• Arrange a briefing note or staff training for the relevant social workers to remind them of the requirements about the administration, storage and transportation of prescribed medication for children in local authority care; and
• Remind officers who deal with complaints of the requirement to signpost to the LGSCO once the Council has completed its complaint investigation.

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Final decision

48. I have completed my investigation with a finding of fault causing injustice for the reasons explained in this statement. In my view, the agreed actions listed in the section above provide an appropriate remedy for the injustice caused by fault.

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Investigator's decision on behalf of the Ombudsman