Summary: The Council was at fault in delaying the children’s statutory complaints procedure in Ms Y’s case. It was not at fault in the way in which it investigated her complaint at stage two and three of the procedure. We recommend the Council should remedy the uncertainty caused to Ms Y by making her an additional symbolic payment.

The complaint

1. Ms X complained on behalf of Ms Y, who had been a looked after child. Ms Y complained that the Council was at fault in placing her in an unsuitable care placement in December 2022 and failing to remove her from it within a reasonable timescale.
2. Ms Y said that the failure to consider foster care for her had negatively impacted her mental health, education and welfare. She also complained about the handling of the complaint through the statutory children’s complaints procedure.
3. Ms Y wants the Council to compensate her for the impact of its failings.

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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 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)
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)
6. 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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How I considered this complaint

7. I considered evidence provided by the Council and Ms X on behalf of Ms Y, as well as relevant law, policy and guidance. I also discussed the complaint with Ms X on the telephone.
8. Ms X, Ms Y and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Statutory complaints procedure

9. The law sets out a three-stage procedure for councils to follow when looking at complaints about children’s social care services. The accompanying statutory guidance, ‘Getting the Best from Complaints’, explains councils’ responsibilities in more detail. We also published practitioner guidance on the procedures, setting out our expectations.
10. The first stage of the procedure is local resolution. Councils have up to 20 working days to respond.
11. If a complainant is not happy with a council’s stage one response, they can ask that it is considered at stage two. At this stage of the procedure, councils appoint an investigating officer (IO) to look into the complaint and an independent person (IP) who is responsible for overseeing the investigation and ensuring its independence.
12. Following the investigation, a senior manager (the adjudicating officer – the AO) at the council should carry out an adjudication. The AO considers the IO report and any report from the IP. They decide what the council’s response to the complaint will be, including what action it will take. The adjudicating officer should then write to the complainant with a copy of the investigation report, any report from the independent person and the adjudication response.
13. The whole stage two process should be completed within 25 working days but guidance allows an extension for up to 65 working days where required.
14. If a complainant is unhappy with the outcome of the stage two investigation, they can ask for a stage three review by an independent panel. The council must hold the panel within 30 working days of the date of request and then issue a final response within 20 working days of the panel hearing.
15. The statutory children’s complaints procedure was set up to provide children, young people and those involved in their welfare with access to an independent, thorough and prompt response to their concerns. Because of this, if a council has investigated something under the statutory children’s complaint procedure, the Ombudsman would not normally re-investigate it.
16. However, we may look at whether there were any flaws in the stage two investigation or stage three review panel that could call the findings into question. We may also consider whether a council properly considered the findings and recommendations of the independent investigation and review panel, and whether it has completed any recommendations without delay.

What happened

2024

17. In January 2024, Ms Y complained (with help from Ms X) about the unregulated care placement the Council had placed her in from December 2022 to September 2023. She complained that:
• The placement was 60 miles from her school during her GCSE year. It was in a remote location and was staffed by care workers from a care agency (the Care Agency). She said the placement had a damaging effect on her ability to prepare for and take GCSEs (she did not sit them).
• The Care Agency staff spoke to her and treated her without care or respect, did not help her to prepare food, reported her missing to the police when they knew she was at her boyfriend’s house, refused to take her to hospital when she fainted with pain, neglected to pick her up from an agreed location at an agreed time (in the middle of the night), and did not take her to dental or health appointments.
• The Council did not provide her with enough clothes or food.
• The Council did not respond to a complaint she made in February 2023 about the staff leaving her on a roadside, late at night, in thin clothing.
• A lone male member of Care Agency staff collected her from a friend’s house in the middle of the night.
• When she resisted the Council’s plan to move her into semi-independent living, a foster placement (in her preferred location) was found immediately – which was what she had wanted all along. She asked why it could not have been found sooner, and why the Council had told her foster care was not an option.
18. The Council did not respond to this stage one complaint. In late April, Ms X requested the complaint be escalated to stage two of the statutory children’s complaints procedure
19. The IO completed their stage two report in mid-September. The report grouped the 29 complaints from the January 2024 letter and two issues from Ms Y’s February 2023 complaint (that the Council had not previously been responded to) into nine areas of complaint.
20. The IO report upheld three of the nine areas of complaint:
• That the Council had not responded to Ms Y’s February 2023 complaint and that the events could not now be investigated, due to the passage of time.
• That the location of the placement was unsuitable, and this had an (unquantifiable) impact on Ms Y’s education.
• That Ms Y had been collected from her friend’s house by a lone male member of staff. The Council had investigated this matter separately, as a safeguarding incident. The concern had been substantiated and a staff member had been dismissed. There was no evidence that the incident resulted in direct harm to Ms Y, rather that the Care Agency had not adhered to agreed protocols.
21. The report partially upheld one further area of complaint, that of poor treatment by staff from the Care Agency.
22. The other five areas of complaint were not upheld.
23. The IP wrote their own report to accompany the IO’s report, stating that they agreed with the findings of the IO report.
24. The AO issued their adjudication report, along with the IO and IP reports, in late October. The adjudication report included:
• A specific response to each of the Ms Y’s desired outcomes from the complaint;
• Details of the action the Council would take in response to Ms Y’s complaint, in the form of training managers in responding to and handling complaints. This action was taken to ensure that other children and young people would have their complaints responded to in a timely way in future, and
• Acceptance of the IO’s recommendations, including a detailed apology, and an offer of a symbolic payment of £250 for the injustice caused by the elements of the complaint that the IO had upheld.
25. On the day the AO issued the adjudication report, the Council sent a separate apology and an offer of £150 to acknowledge the “stress and uncertainty” caused by the delay in the stage two investigation.
26. In late November, Ms X asked the Council escalate the complaint to stage three.

2025

27. In mid-January 2025, Ms X submitted Ms Y’s account of why she disagreed with the findings of the stage two investigation and was seeking an increased financial remedy.
28. The stage three Panel met in mid-March. The Panel Chair completed the Panel Report a few days later. The Report explained that the Panel meeting had been delayed because the Chair had rejected both suggested panel members as they had been involved with Ms Y’s previous complaints.
29. The Panel Report:
• Considered the views of all parties;
• Asked questions of the Council’s officers;
• Overturned some findings from stage two:
1. Ms Y had complained that she had been told by a member of Care Agency staff that a placement in her preferred location was available – the Council said it was not. The Panel changed the finding for this complaint from “not upheld” to “no finding”, because no one else was present during the conversation and it was not known what the property being discussed was.
2. Complaint about a failure to provide proper medical, dental care and emotional care. The Panel changed this finding from “not upheld” to “partially upheld” because of a delay that occurred when Ms Y was referred to Child and Adolescent Mental Health Services.
3. Complaints about the Council pressuring Ms Y to move to semi-independent living and foster care having not being considered. The Panel changed this finding from “not upheld” to “partially upheld” because the sudden offer of a foster placement without any preparatory discussion had not been explained.
• Made one recommendation about complaint handling; and
• Did not recommend an increase in remedy payment.
30. The stage three adjudication was issued by a senior Council officer in early April. The adjudication offered further apologies, agreed with the Panel’s findings, and provided further detail on the reasons for some of the stage two findings being overturned at stage three. It agree to implement the Panel’s recommendation about complaint handling, which was that the Council should clarify the process and responsibility for the oversight of complaints made directly to a provider.
31. Ms X complained to the Ombudsman on behalf of Ms Y in late May 2025.

Analysis

32. As set out at paragraph 15 and 16, the Ombudsman does not re-investigate complaints that have been considered via the full children’s statutory complaints procedure.
33. The statutory procedure differs from other complaints processes because of the level of independence required as part of the complaint consideration at stages two and three. Stage two investigations are more in depth than in other complaint processes, and the work of the IP makes the stage two investigation even more powerful. The IP exercises oversight over the IO’s investigation, providing assurance that it was sufficiently thorough, independent and transparent.
34. The stage three review Panel provides a valuable opportunity for the complainant to reach a resolution with the council, which addresses their concerns and remedies any injustice. The Panel is made up of three independent people who hear the arguments of both the complainant and the council.
35. And so, I shall confine my findings below to whether:
• There were any flaws in the complaints process;
• The Council properly considered the findings and recommendations of the independent investigation and review panel; and
• It has completed any recommendations without delay.

Handling of Ms Y’s complaint and the impact on her

36. The Council should have responded to Ms Y’s stage one complaint about her care placement within 20 working days. It did not do so. After waiting for 60 working days, Ms X felt it necessary to escalate Ms Y’s complaint to stage two. This delay was fault and caused Ms Y a period of uncertainty, as well as a missed opportunity to resolve her complaint at an early stage. The Council did not offer Ms Y either an explanation for the delay nor a financial remedy for the injustice caused, and I shall therefore recommend a remedy.
37. The whole stage two process should be completed within 25 working days but guidance allows an extension for up to 65 working days. The Council took 129 working days to respond at stage two of the statutory process from when Ms X and Ms Y made their stage two complaint, to when the Council issued its adjudication. This was double the maximum duration allowed, and was fault. The Council apologised for the “stress and uncertainty” caused by this delay. It made Ms Y a payment of £150 in recognition of the injustice caused by the delay, that I consider an appropriate remedy.
38. The Council must hold the stage three panel within 30 working days of the date of request and then issue a final response within 20 working days of the panel hearing. The Panel meeting took place more than 70 days after Ms X made the stage three request, which again was more than double the maximum duration allowed. This delay caused Ms Y ongoing uncertainty. The stage three adjudication was issued within 20 days of the panel hearing and was not fault. The Council did not recommend a financial remedy for the injustice caused by the further delay at stage three and so I shall do so.
39. The Council offered Ms Y a symbolic payment of £250 for the injustice caused by the matters that were upheld and partially upheld at stage two. The Panel upheld additional complaints at stage three that had caused Ms Y uncertainty, but it did not did not increase this remedy payment. I consider that this leaves some of Ms Y’s injustice unremedied and so I shall make a further recommendation.

Implementation of recommendations

40. The Council accepted the stage two and stage three findings. The stage two adjudication said that the Council had planned some training with managers from across its services about responding to and handling complaints. During this investigation, the Council provided me with evidence that it had delivered this training in November 2024. I am satisfied that the Council implemented the recommendation that was made during the independent investigation stage.
41. The stage three adjudication accepted the Panel’s recommendation that the Council should “clarify the process and responsibility for the oversight of complaints made directly to a provider”. During this investigation, the Council told me that “Children’s Services are engaging directly with providers regarding complaints to ensure they are working to find a resolution as part of QA [Quality Assurance].” Based on this response, I am not satisfied that the Council has implemented the recommendation that was made by the review Panel. I have therefore made a further recommendation.

Service improvements

42. The Ombudsman investigated another complaint about the Council’s handling of children’s social care complaints. The Council sent us a plan, in December 2023, of the action it was taking to improve the service. During this investigation, I asked the Council to provide an update of progress that has been made against the action plan since then. It failed to do so and I have made a recommendation to address this.

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Action

43. Within one month of the final decision, the Council has agreed to:
1. Make Ms Y a payment of £300 in recognition of the additional impact of its failings on her. This payment is recommended in addition to the £400 it has already paid to Ms Y through the complaints procedure; and
2. Provide the Ombudsman with an update on the progress it has made in implementing the action plan it created in response to the investigation of an earlier case.
44. Within three months of the final decision, the Council has agreed to: work with Care Providers to implement a process that ensures the Council has oversight of complaints made directly to Care Providers about Council-commissioned services.
45. The Council should provide us with evidence it has complied with the above actions.

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Decision

46. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman