Plymouth City Council (24 001 826)
Category : Children's care services > Looked after children
Decision : Upheld
Decision date : 07 Nov 2024
The Ombudsman's final decision:
Summary: We found fault on Miss W’s complaint about the way the Council dealt with her daughter when it decided to place her for adoption. It delayed telling her of abuse by the prospective adopter and a change of circumstances for almost two years. Records were incomplete, there was a failure to promptly get guidance, and case management was weak. The agreed action remedies the injustice caused.
The complaint
- Miss W complains about the way the Council dealt with her daughter X when it decided to place her for adoption and its failure to:
- place her with prospective adopters who would not abuse her;
- promptly tell her about the abuse; and
- tell her of its decision to abandon plans for her adoption with them.
- As a result, this affected her mental health due to worrying about what happened and also wrongly believing X had been adopted years ago.
The Ombudsman’s role and powers
- 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)
- 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 the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
- Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).
How I considered this complaint
- I considered all the information Miss W sent, the notes I made of our telephone conversation, and the Council’s response to my enquiries. I sent a copy of my draft decision to Miss W and the Council.
What I found
- Miss W’s daughter, X, was made subject to a Child Protection Plan in 2017 by the Council because of concerns about her mother’s ability to provide for her emotional well-being.
- The following year, the Council told Miss W because of continuing concerns, it would start care proceedings. Shortly after, the police removed her children, including X, and placed them in the Council’s care.
- With no wider family members who could care for X, the court made a placement order for adoption in 2019. A placement order is an order made by the family court which allows a council to place a child for adoption with prospective adopters who have passed all the checks and are a suitable match for the child. This is even where a parent disagrees.
Complaint a): placing with abusive prospective adopter
- Miss W’s daughter was placed with a prospective adopter who, in August 2021, told the Council she would not accept X back into her care. This was after a period of respite care.
- The Council then placed X with foster carers. While there, the carers noted she had a bruise on her head. X said this was because she was hit over the head with an electronic tablet. The child protection medical examination was inconclusive as X refused to speak to the doctor and there was no clear explanation for the bruising. The Council could not conclude the bruising was intentional.
- Several months later, it decided X would not return to the prospective adopter as it was satisfied concerns were proven. This was after further disclosures of harm by X during her time with the prospective adopter. She would remain with foster carers.
- The Council confirmed no concerns about abuse were raised at the point of matching the prospective adopter with X. It sent a copy of the minutes of the adoption panel which considered the prospective adopter. This looked at the strengths and weaknesses of any match with X.
My findings
- I found no fault on this complaint. This was because there was no evidence of any concerns about possible abuse by the prospective adopter at the time it matched her with X. The adoption panel minutes raise no concerns at all about the prospective adopter and abuse. I also note X had spent some time in her foster care without incidence.
Complaint b): promptly tell her about the abuse
- After being alerted to X’s injuries in August 2021, the Council held a strategy discussion. A strategy discussion decides whether the threshold was met for a single or joint agency child protection investigation (for example, with the police) and to plan for it.
- As a result, enquiries under section 47 of the Children Act 1989 were started. These are started to decide whether, and what type of, action is needed to safeguard and promote the welfare of the child who is expected to be suffering, or is likely to suffer, significant harm.
- The result of the enquiries was the concerns were proven with a recommendation for X to remain in her foster placement.
- A Child in Care Review was held the following month to discuss long term plans for X because of what happened.
- In October, a new social worker was allocated to X. Due to Miss W’s mental health, guidance would be sought from the mental health team about contacting her.
- In December, a social work assessment was needed to help show what care plan was right for X.
- In January 2022, the Council decided it unlikely X would return to the care of the prospective adopter but, needed further meetings to consider it.
- The Council decided in March not to return X to the prospective adopter. The case would be returned to the Agency Decision Maker to discharge the placement order. The Agency Decision Maker is responsible for deciding whether a child’s final Care Plan should be for adoption. The same month, the social worker sadly died after being unwell for a period of time. Another social worker took over the case.
- The evidence showed this social worker was asked on two occasions to prepare the necessary paperwork to return the case to the Agency Decision Maker so as to discharge the placement order for X. The social worker failed to do so.
- In March 2023, the case was allocated to another social worker following ‘further significant drift and delay’ on X’s case.
- In May, a case discussion looked at the best way to share information about X with Miss W. As it was thought to be harmful to her mental health to tell her, it agreed to discuss it at a multidisciplinary team (NHS Adult Social Care), which helped support her, to agree a plan. Its concerns were based on evidence in the original care proceedings in 2019 which included assessments. Children Services were, therefore, now taking a lead from Adult Social Care about Miss W’s wellbeing.
- There was no record of the multidisciplinary meeting taking place.
- Adult Social Care suggested a telephone meeting in May. There was no record showing this took place.
- In August, the Council contacted Adult Social Care again about the need to talk to Miss W before the discharge of the placement order which was now only a few weeks away. Adult Social Care replied that the officer had been off work.
- It was in January 2024 that the Council decided to get an order from the Department of Works Pension. This order would allow it to get Miss W’s address for communication. The Council took further legal advice, which said it needed to tell Miss W and could no longer wait for feedback from Adult Social Care and mental health support.
- In February, the Council wrote to Miss W and arranged a meeting nine days later with her and her support worker to tell her about X’s situation. The Council apologised for taking 23 months to tell her about X’s situation. This was due mainly to various changes of social worker and teams X had over the period. It accepted she was never formally told what was happening with X. As she had parental responsibility for X until an adoption order was made, she should have been told and invited to meetings as appropriate.
- The placement order was revoked in September. The Council accepted the court might have revoked the placement order sooner had it applied earlier.
- It also explained during legal proceedings, and because of Miss W’s mental health, there was no communication between the allocated social worker and Miss W. Nor was there communication between the X’s Guardian and Miss W. It accepted this hindered its ability to share relevant information with her and keep her updated about the adoption process.
- The Council apologised for significant delays with X’s care planning.
My findings
- I found fault on this complaint for the following reasons:
- The Council decided to seek guidance from mental health teams in October 2021. This was to consider how to contact Miss W about developments. There was no evidence showing what action was taken at this point to seek guidance. As a result, the Council missed an opportunity to tell Miss W about the abuse promptly.
- In March 2022, the Council decided it would not return X to the prospective adopter. The Council failed to tell Miss W about this decision and nor did it seek guidance from the mental health teams about how to contact her about this decision. Again, it missed an opportunity to tell Miss W about this decision promptly.
- The social worker failed to take the required steps for the discharge of the placement order despite two requests to do so. I consider this showed weak case management as the failure to do the tasks given should have been identified sooner.
- The Council accepted the case was allocated to another social worker in March 2023 after significant drift and delay. I am satisfied this also was evidence of weak case management.
- One year after the new social worker received the case, in May 2023, there was an agreement to discuss the case with a multidisciplinary team. There was no evidence to show this happened. Again, this also showed weak case management.
- There was contact with Adult Social Care but there were months of delay and no evidence a suggested telephone discussion happened.
- I appreciate the Council was understandably concerned about the possible impact telling Miss W about the abuse and its decision not to continue with the prospective adopter would have on her. Taking this in to account, I am satisfied it took too long to tell her about these developments. It also took too long to get guidance and advice about how best to communicate what had happened with her.
- I am satisfied the identified fault caused Miss W an injustice. This caused her avoidable distress. She was unaware of what had happened for about 23 months and when told after such a long delay, it caused her anxiety, frustration, and upset.
Complaint c): tell her of its decision to abandon plans for her adoption with them.
- Miss W complained about the time taken to tell her of its decision to not proceed with the adoption process for the prospective adopter. She also complained she was told X had been adopted and that was final. Miss W argued this affected her mental health.
- The Council apologised for giving her misleading information about the adoption process at the time the placement order was made as adoption was not final when X was placed with a prospective adopter. It would only be final when an adoption order was made, and she would have been told about those proceedings.
- The Council also apologised for failing to tell her what was happening with X. it explained as she kept parental responsibility, she should have been told and invited to meetings where appropriate.
My findings
- I found fault on this complaint. The Council delayed telling her of its decision not to proceed with the prospective adopter by about 23 months.
- I am satisfied this caused her injustice. She was unaware of what had happened for almost two years which caused her anxiety, frustration, and upset when she eventually found out.
- I also found fault on her complaint about it giving her misleading information. This was because the Council accepted it had done so.
- I am also satisfied this caused her an injustice. This was because she misunderstood the situation and missed being invited to potential meetings she could have attended.
Agreed action
- I considered our guidance on remedies. I also considered the apologies the Council gave for significant delays on her case.
- The Council agreed to take the following action within six weeks of the final decision on this complaint:
- Send Miss W an apology for failing to: get mental health guidance in October 2021; ensure there was effective management of social workers involved; keep a record of the multiagency meeting.
- Make a payment of £300 to Miss W for the injustice caused by the fault.
- To review why the identified delays took place and act to ensure they are not repeated on future cases.
- To review the management failings identified and act to ensure they are not repeated on future cases.
- The Council should provide us with evidence it has complied with the above actions.
Final decision
- I make the following findings on the complaint made by Miss W against the Council:
- Complaint a): no fault;
- Complaint b): fault causing injustice; and
- Complaint c): fault causing injustice.
Investigator’s decision on behalf of the Ombudsman
Investigator's decision on behalf of the Ombudsman