Summary: Miss Y complains the Council did not properly investigate the injuries her child obtained whilst in Council arranged foster care. We find procedural fault which creates uncertainty about the Council’s consideration of the injuries. The Council will pay £500 in recognition of that distress and remind staff of the protocols when considering allegations made against those working with children.

The complaint

1. Miss Y complains about failures in the Council’s investigation after her child sustained injuries in foster care. She says that due to those failures no explanation has been provided about the injuries, and other foster children may still be at risk.

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The Ombudsman’s role and powers

2. 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)
3. 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)
4. 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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What I have and have not investigated

5. I have investigated the Council’s consideration of the non-accidental injuries which Miss Y’s child obtained whilst in local authority foster care.
6. I have not investigated what happened before D was placed into foster care. This is because the decision to place D into care, and the circumstances leading to that decision, were considered by the courts and are therefore outside of our jurisdiction.

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How I considered this complaint

7. I considered evidence provided by Miss Y and the Council as well as relevant law, policy and guidance.
8. Miss Y and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
9. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).

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What I found

Local Authority Designated Officer (LADO)

10. The LADO is a person responsible for managing and overseeing investigations into allegations that somebody who works with children has behaved in a way that may pose a risk to children. The LADO is responsible for:
• providing advice to employers.
• managing and overseeing cases.
• ensuring the child’s voice is heard and that they are safeguarded.
• ensuring there is a consistent, fair and thorough process for all adults working with children and young people against whom an allegation is made.
• monitoring the progress of cases to ensure they are dealt with as quickly as possible.
11. The ‘National Fostering Minimum Standards’ say: “Allegations against people that work with children or members of the fostering household are reported by the fostering service to the LADO. This includes allegations that on the face of it may appear relatively insignificant or that have also been reported directly to the police or Children and Family Services.”
12. The ‘London Safeguarding Children Partnership’ sets out the responsibilities of LADOs working within London boroughs. It says:
• All concerns reported to the LADO should be assessed to decide if the threshold for an allegation has been met. In cases where it is not clear whether the threshold has been met, it might be necessary to have a discussion (by phone or in a meeting) to evaluate whether the threshold is met – sometimes referred to as an evaluation meeting.
• The employer and the LADO should discuss the incident and to decide whether it meets the threshold for risk of harm. Consideration should be given to the risk or potential risk to both the child/children directly affected by the issue and any other children who may also be at risk.

13. The procedures say, if the allegation is not “demonstrably false” and there is cause to suspect that the adult poses a risk of harm, the LADO should convene an Allegations against Staff and Volunteers (ASV) meeting/discussion. An ASV meeting will normally only be arranged when it has been decided that the threshold of harm or risk of harm has been met. 

Summary of key background events relevant to the complaint

14. This section of the statement provides a summary overview of the key events relevant to the complaint. It does not include every event which happened. Key dates are removed to protect the anonymity of Miss Y and her family.
15. Miss Y has a young child who I will call D. In April 2023 D experienced unexplained bruising and Miss Y took him to the doctors. A safeguarding referral was made based on a professional opinion that D’s bruising looked to be non-accidental. The Council obtained an Interim Care Order (ICO) and D went to live with foster carers.
16. On a date in early May 2023 the social worker completed a supervisory visit at D’s foster placement. As part of the visit, the social worker took photographs of D.
17. Miss Y had regular supervised contact with D during their time in care. During a contact visit on the day after the social worker’s visit, Miss Y noticed multiple new bruises on D’s arms and left shoulder. She immediately raised concerns due to the location and extent of the bruising. The allocated social worker took D to the doctors. D was admitted to hospital and received a child protection medical and review.
18. The Council moved D to a different placement after their discharge from hospital.
19. The social worker also met with the foster carer to obtain their account of events.
20. Following the outcome of the medical, the Council held a strategy meeting. This took place within one working day of Miss Y finding the new bruises. The purpose of the meeting was to consider whether the threshold for risk had been met and consequently whether the events leading to D’s injuries met the criteria for a child protection investigation under S47 of the Children Act.
21. The notes of that meeting show discussion around D’s injuries and the doctor’s view that the bruising was non-accidental, with the largest bruise possibly caused by a bite.
22. The foster carer also provided their logs. The logs showed that D was heavy-handed, tearful and reactive. Whilst in the placement, the foster carer said D had hit the TV, thrown themselves on furniture and sometimes banged into things through clumsiness. The foster carer also logged that D had bitten another child.
23. The Police representative in attendance said they would struggle to determine who caused D’s injuries as the household accommodated lots of children. Police said there was no further role for them.
24. The Chair of the strategy meeting commented that there was nothing to warrant a LADO referral. The outcome of the meeting was recorded as “not sufficient information to consider a role for the LADO in light of child’s presentation and difficulties”.
25. A Consultant Paediatrician reviewed photographs and records to produce an ‘Expert Witness’ report in early January 2024 for ongoing care proceedings. The report concluded: “on balance of probabilities, this injury is likely to be bruising due to a bite mark. I have arrived at this conclusion by reviewing the shape, size, location and pattern of healing of the bruise. It has a characteristic shape of raised margins with central clearing suggestive of a bite mark”.
26. In January 2024 the court ordered D to be returned to Miss Y. The Council ended its social care involvement with D and their parents.
27. Mrs Y contacted her MP and complained to the Council. The Council issued its final complaint response on 8 October 2024. In summary, the Council said:
• Having reviewed the records of the strategy discussion, it was decided there was no benefit in pursuing a child protection inquiry. The LADO agreed an investigation would not provide any further information.
• “Whilst the police officer and LADO had clear views in respect of progressing an investigation, their decision making was contrary to guidance provided to child protection professionals”.
• “I am unable to open an investigation now due to evidence being lost” but “… there is learning for social workers and the wider partnership”.
28. Dissatisfied with the response, Miss Y complained to the Ombudsman.

Was there fault causing injustice to Miss Y?

29. We cannot set out everything the Council did after being told about D’s bruising in May 2023, as some of the information is confidential and relates to third parties. However, the records show that the Council took prompt and appropriate action to immediately safeguard D once it became aware of the injuries. That said, we have found that the Council did not always follow the correct procedures when assessing the situation and any ongoing risk.
30. When making enquiries of the Council, we asked it to explain how the LADO’s decision making was considered to be “contrary to guidance”. The Council explained the LADO was on annual leave at the time of the strategy meeting on in May 2023. As a result, the LADO’s line manager, who was a senior manager, stepped in to cover for the LADO. The same manager also acted as Chairperson. The Council says this was not in accordance with the procedures as the meeting is usually chaired by a manager in the safeguarding team. However, the LADO’s line manager was the most senior person in attendance at the meeting.
31. Section 4.8.10 of the statutory guidance ‘Working Together to Safeguard Children' says that: “Local authorities should have a designated officer, or team of officers, to be involved in the management and oversight of allegations against people who work with children.” This is because The LADO function is not person-dependent; it’s an institutional responsibility that cannot pause due to absence or leave. Although the LADO’s replacement acted in a dual role during the strategy meeting (as both LADO and Chair) I am not persuaded this procedural fault caused any significant injustice to Miss Y.
32. However, the Council also acknowledges there should have been a separate meeting with the same professionals to review the evidence again and to decide whether the threshold for a LADO referral was met. The Council decided not to proceed to a separate meeting under the LADO procedures. It said this was to prevent duplication by considering the same evidence again and potentially leading to the same outcome. This approach was fault.
33. When considering Miss Y’s complaint, the Council also said it had lost key records. Although the Council has not clarified the extent of that loss, Miss Y believes it to be the photographs of D taken by the social worker in May 2023; one day before Miss Y identified the bruising on D’s upper body. Miss Y considers those photographs are key because they demonstrate that D did not have bruises when the social worker took their photographs. She says there were 19 hours between the Council taking those photographs and the discovery of the new bruises. Miss Y says the Council should be able to shortlist who had contact with D in that period.
34. Although the photographs may have evidenced the absence of bruising at the time of the social worker’s visit, almost a whole day elapsed before D’s bruises were observed. During this time, D had contact with multiple other adults and children in the placement. Given this, on the balance of probabilities, I am not persuaded the existence of the photographs would have provided conclusive evidence regarding the timing or cause of D’s injuries.
35. While it is not possible to say, on the balance of probabilities, whether the outcome of the strategy meeting would have been different had there been no procedural fault, it is acknowledged that Miss Y has experienced injustice in the form of avoidable frustration and uncertainty. This is because Miss Y says the Council did not properly consider all available evidence and she says this most likely affected the outcome. I also consider that Miss Y experienced further frustration from the Council’s handling of her complaint. This is because the complaint response was vague and did not provide enough detail for Miss Y to understand the procedural failures the Council had identified.
36. In light of the uncertainty and frustration caused by fault, the Council has agreed to apologise and make a symbolic payment of £500 to Miss Y. It will also complete the service improvements we have outlined in the following section of this statement.

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Action

37. Within four weeks of my final decision, the Council has agreed to:
• Apologise to Miss Y and make a symbolic payment of £500. 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.
38. Within twelve weeks of my final decision, the Council will also:
• Remind relevant staff – including the LADO, their manager and those usually responsible for chairing strategy meetings – of the importance of adhering to the published protocols for managing allegations against people who work with children.
• Provide information of the learning already shared (for social workers and the wider partnership) as outlined in the Council’s final complaint response.
• Conduct a review of the reported data loss to establish which specific files and information were affected. Following identification, the Council should consider formally referring the loss to its Information Governance team for further assessment and appropriate action in line with data protection protocols.
39. The Council will provide us with evidence it has complied with the above actions.

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Decision

40. I find procedural fault causing injustice to Miss Y. The Council will complete the actions listed above to remedy the injustice caused by fault

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman