Summary: The Council was at fault in its adjudication of Miss X’s complaint that followed a stage three Panel review as part of the statutory children’s complaints procedure. The Council’s fault caused Miss X and her family frustration and uncertainty and put Miss X to time and trouble. The Council should agree actions to remedy the injustice caused and to improve its service.

The complaint

1. Miss X complained the Council failed to deal properly with her complaint about her child, Y’s, care placements. She said the Council hasn’t properly implemented the recommendations of the statutory children’s complaints procedure as the remedy offered doesn’t reflect the impact on her family, in terms of the avoidable distress caused.

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The Ombudsman’s role and powers

2. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
3. 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)
4. 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 have and have not investigated

5. 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 process, the Ombudsman would not normally re-investigate it.
6. 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.
7. I have therefore not investigated Miss X’s concerns about the care placements the council arranged for Y. I have only investigated the way in which the Council considered her complaints via the statutory children’s complaints procedure.

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How I considered this complaint

8. I considered evidence provided by Miss X and the Council as well as relevant law, policy and guidance.
9. Miss X 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

Law, policy and guidance

The three-stage process

10. The Children Act 1989 Representations Procedure (England) Regulations 2006 (the Regulations) 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’ (the Guidance), explains councils’ responsibilities in more detail. We also published practitioner guidance on the procedures, setting out our expectations.
11. The first stage of the procedure is local resolution. Councils have up to 20 working days to respond.
12. 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.
13. Following the investigation, a senior manager (the adjudicating officer – AO) at the council should carry out an adjudication. The officer 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.
14. 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.
15. 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.

The Regulations and Guidance

16. Section 20(3) of the Regulations states that after a stage three panel meeting, the council’s final response must “consider the recommendations [made by the panel] and determine – (a) how the authority will respond to them; and (b) what they propose to do in light of them, and send to the complainant its response and proposals”.
17. The Guidance includes (at section 3.18.1) that, after the Panel, “The local authority must send its response to the Panel’s recommendations to the complainant (and other participants as necessary) within 15 days of receiving the Panel’s report (regulation 20(3)). The response should be developed by the relevant Director/Director of Children’s Services setting out how the local authority will respond to the recommendations and what action will be taken. If the Director deviates from the Panel’s recommendations he should demonstrate his reasoning in the response. In developing his response he should invite comment from all the attendees including the Independent Person from Stage 2 (regulation 20(3))”.

What happened

18. In late April 2024, Miss X complained about the care placements the Council had placed her child, Y, in between September 2022 and December 2023. Miss X complained that:

Complaint 1: The first Council officer had pressured her into signing the agreement that allowed the Council to place Y in care;

Complaint 2: The Council did not check whether the two foster placements it put Y in were appropriate;

Complaint 3: The second Council officer developed a personal relationship with Y’s father and brought him to Miss X’s home against her wishes;

Complaint 4: The second Council officer worked with Y’s father to arrange for Y to be placed in a care home against Miss X’s wishes;

Complaint 5: A carer in the care home showed Y indecent photos from dating applications;

Complaint 6: Staff in the care home mocked Y about their weight;

Complaint 7: The lack of care and attention within the care home caused Y’s hygiene and mental health to deteriorate significantly;

Complaint 8: Y began to self-harm while resident in the care home. Miss X said this was because the home did not provide Y with the therapy it had promised, but did provide Y with access to razors and aerosols;

Complaint 9: The care home did not notice Y had absconded until Miss X called to say Y had turned up at her home; and

Complaint 10: The Council had failed to provide “proper intervention, therapy, or medical support” for Y’s deteriorating mental health.

19. The Council acknowledged the complaint in early May 2024 but did not respond to it.
20. In mid-November 2024, Miss X asked for the complaint to be escalated to stage 2 of the complaints procedure. The Council acknowledged her request and assigned the investigation to an IO.
21. In December 2024, the Council offered Miss X a payment of £350 in recognition of the fact it had not investigated her complaint at stage one.
22. The IO completed the report of their investigation in mid-April 2025. The report said that the IO had:
• Interviewed the complainant;
• Considered the social care records and other relevant information;
• Interviewed staff and other people relevant to the complaint;
• Liaised with the IP; and
• Analysed all available relevant information.
23. The IO’s report made findings on 11 complaints: the ten set out above, plus a further complaint about the Council’s delays in responding to Miss X’s complaints.
24. The IO’s findings and conclusions for each of the 11 complaints were as follows:

Complaint 1: Not upheld: The first Council officer explained the consequences of signing the Section 20 agreement. Miss X withdrew her agreement some days later, before re-signing: she was only able to do this because she was aware of her rights.

Complaint 2: Partially upheld: The first foster placement was “not appropriate or culturally matched”, but in both the first and second foster placement the Council was placed in a difficult situation because of the urgency of the situation and the local and national shortage of foster carers.

Complaint 3: No finding: The second Council officer had left the Council’s employment since the time of the events. The IO was able to contact them by phone, and sent them questions by email, but they declined to respond. The social care records did not include the incident in question.

Complaint 4: Not upheld: The Council had applied for an Interim Care Order to share parental responsibility for Y, and arranged to move them to the care home, before the second Council officer was assigned to Y’s case.

Complaint 5: Upheld: The care home had carried out two investigations into this complaint. The care home found two workers responsible and had dismissed them from employment. The care home had also notified the Local Authority Designated Officer, Ofsted, the Council’s social care team, and the Disclosure and Barring Service. The IO considered this a satisfactory response to the incident.

Complaint 6: Inconclusive: The IO found the care home’s notes reflected “much care and thought from staff […] in relation to positive body image”. The IO noted that Miss X often commented on Y’s diet and weight, and asked the care home to place restrictions on what Y ate.

Complaint 7: Not upheld: The IO found that Y managed much of their own laundry and hygiene, and that this was normal practice for a young teenager in the care home. Staff encouraged Y to clean their room and do their laundry and had no concerns about Y’s cleanliness.

Complaint 8: Partially upheld: It was factually correct that Y began to self-harm in the care home. However, staff completed extensive risk assessments, followed all relevant procedures to minimise harm and “did all they could to keep sharp objects away from [Y]”.

Complaint 9: Partially upheld: It was factually correct that Y did travel to Miss X’s home without the staff of the care home being aware. But an earlier investigation had found that staff had followed the correct procedures in letting Y out for an evening walk on the understanding they would keep in touch and adhere to their curfew. Y had lied to staff and had obtained financial support to make the journey.

Complaint 10: Not upheld: The IO found that the Council had attempted to provide “mental health support by way of a Therapeutic Care Plan including support from a Clinical Psychologist”, but that Y was “not always willing to fully engage in therapy”.

Complaint 11: Upheld: The Council had not responded to Miss X’s stage one complaint. The IO considered the payment of £350 offered by the Council in recognition of this was appropriate. They noted that there had been further delays during stage two and recommended the Council should consider making Miss X a further payment in acknowledgement of this.

25. The IO recommended that the Council should source an advocate for Y and refer them to a therapist if it had not already done so.
26. The IP wrote their own report to accompany the IO’s report, stating that they agreed with the findings of the IO report and had not identified any issues with the IO’s investigation.
27. The AO issued their adjudication report, along with the IO and IP reports, in mid-May. The adjudication report included that the Council agreed with all the findings and recommendations of the stage two investigation. The AO offered Miss X a payment of £150 in recognition of the injustice caused by the delay in investigating her complaint at stage two.
28. Miss X asked the Council to escalate the complaint to stage three.
29. The stage three Panel met in late July. The Panel Chair completed the Panel Report a few days later. The Panel Report:
• Considered the views of all parties (including the IO, the IP, and Miss X, all of whom attended);
• Asked questions of the Council’s officers;
• Overturned some findings from stage two;
• Recommended the Council should apologise for several aspects of Y’s care and Miss X’s experience.
30. The findings the Panel overturned were:

Complaint 2: Changed from partially upheld to upheld: The Panel noted the Council’s constraints in sourcing foster placement, but found that neither of the foster placements were suitable for Y.

Complaint 3: Changed from no finding made to upheld: The Panel found Miss X’s account of this incident “compelling” and said “neither the investigating officer nor the Council were able to provide any contradictory evidence to refute this account. The Panel did not have any reason to dismiss [Miss X’s] account”.

Complaint 7: Changed from not upheld to partially upheld: The Panel noted that the IO’s report did not address the aspect of this complaint relating to Y’s mental health. It found that “while some work was completed more could have been done to support these areas of [Y’s] life”.

Complaint 9: Changed from partially upheld to upheld: The Panel found that Y “had a history of going missing”, and that “staff only texted [Y]” to check in with them, whereas “a phone call might have alerted the staff to the fact that [Y] was on a train”.

31. The Panel recommended the Council should apologise to Miss X and Y for the following aspects of their experience:
1. The first foster placement that did not meet all Y’s needs;
2. The second foster placement that ended with the carer pouring ketchup over Y’s clothes;
3. The second Council officer taking Y’s father to the family home;
4. The residential placement that did not effectively address Y’s risks of self-harm;
5. Care home workers who showed Y sexually explicit images;
6. Y being able to return to Miss X’s home without the knowledge of the care home staff;
7. A fractured relationship where Y no longer trusts social care staff;
8. The Council’s failure to respond to the stage 1 complaint;
9. For the distress that all of the above have caused.

32. The Panel also recommended that the Council should consider whether separate financial remedies for Miss and Y were warranted for any of these matters.
33. The stage three adjudication letter was issued by a senior Council officer (the second AO) in late August. The letter said “ This adjudication will set out whether the council agrees with the findings and conclusions of the investigation and, where relevant, will also provide details of any recommendations”.
34. The second AO disagreed with some of the Panel’s findings as follows:

• Complaint 2: Changed from upheld to partially upheld.
• Complaint 3: Changed from upheld to inconclusive.
• Complaint 7: Changed from partially upheld to not upheld.
• Complaint 9: Changed from upheld to partially upheld.

35. The letter gave no reasons for the second AO’s disagreement with the Panel’s findings.
36. The second AO agreed to implement Panel recommendations b), e), g) and h) only. The letter said “Council disagrees with the factual accuracy of some of the report’s findings under this section. The Council cannot therefore issue a blanket apology for all the points”.
37. The Council offered symbolic payments of £550 to Y for the injustice caused by the Council’s failings in relation to b), e), and g), and £200 to Miss X for the injustice caused by g).
38. Also in late August 2025, Miss X complained to the Ombudsman.

The Council’s response to my enquiries

39. I asked the Council why, given that the Children’s Statutory Complaints Procedure does not include provision for councils to overturn the findings and conclusions of the stage 3 Panel, the second AO had done so in relation to complaints 2, 3, 7 and 9. The Council responded that “there is no provision in the Guidance stating Local Authorities cannot disagree with a Panel’s decision”.
40. I also asked the Council why, when disagreeing with the Panel’s recommendations a), c), d), f), and i), the second AO had not given their full reasoning for doing so. The Council responded:

“The Council recognises that where the Stage 3 Director, acting as adjudicator, deviates from the Panel’s recommendations, the Director must contact the parties concerned for comments and reasoning must be provided in the adjudication for all individual points where there is a deviation. On this occasion, due to some staffing issues, including some complaints staff being on annual leave, interested parties were not contacted and reasoning was not provided. The Council is committed to continuous training for staff dealing with children’s complaints and sincerely apologises for this shortcoming and any inconvenience this has caused.”

My findings

41. As set out at paragraph 5 and 6, the Ombudsman does not re-investigate complaints that have been considered via the full children’s statutory complaints procedure.
42. 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.
43. The stage three review Panel provides a valuable opportunity for the complainant to reach a final 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.
44. 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.

Stage one: local resolution

45. The Council should have responded to Miss X stage one complaint within 20 working days. It did not do so. Miss X felt forced to escalate her complaint to stage two without ever receiving a stage one response. This delay was fault and caused Miss X a period of uncertainty, as well as a missed opportunity to resolve her complaint at an early stage. However, the Council offered Miss X a payment of £350 for the injustice caused, which I consider a suitable remedy.

Stage two: independent investigation

46. The IO’s report included the steps the IO took to investigate Miss X’s complaint, including interviewing all relevant parties and considering relevant care records and other information. Their report included details of findings, conclusions and outcomes against each of Miss X’s 11 complaints, and recommendations on how the Council should remedy any injustice to Miss X and Y. The Council was not at fault in its investigation of Miss X’s complaint.
47. The IP’s report demonstrated that they had considered the way in which the IO had conducted the investigation and that they were satisfied with this. The Council was not at fault.

Stage two: adjudication

48. The stage two adjudication report included that the Council agreed with all the findings and recommendations of the stage two investigation. I have seen evidence that the Council implemented the recommendations, including referring Y to a therapist and arranging for her to be represented by an advocate. The Council was not at fault in its stage two adjudication.

Stage two: timescales

49. The whole stage two process should be completed within 25 working days but the Guidance allows an extension for up to 65 working days. The Council took 125 working days to complete stage two of the statutory process from when Miss X made her stage two complaint to when the Council issued its adjudication. This was double the maximum duration allowed, and was fault. The Council made Miss X a payment of £150 in recognition of the injustice caused by the delay, that I consider an appropriate remedy.

Stage three: review Panel

50. As set out above, the third stage is a review panel made up of three independent people. The panel considers the adequacy of the stage two investigation. It can seek more information if needed to resolve the complaint but should not generally reinvestigate or consider new complaints. The panel makes findings on each complaint element and can make new recommendations.
51. In this case, the Panel took evidence from all relevant parties, including the Council, the IO, the IP, and Miss X. Having weighed all the evidence, it came to different conclusions than the stage two investigation in relation to four aspects of Miss X’s complaint. The Panel also made additional recommendations to the Council. The Panel was entitled to make such findings and recommendations and was not at fault in how it decided to do so.
52. The panel should be held within 30 working days of the complainants request. That timescale was adhered to in this case and so the Council was not at fault.

Stage three: adjudication

53. After the hearing, a relevant director considers the outcome of the Panel and issues the council’s adjudication within 20 working days. This timescale was adhered to and so the Council was not at fault in this regard.
54. The Council’s perspective is that there is no provision in the Guidance stating that a Council cannot disagree with a Panel’s decision. The Ombudsman’s view is that there is no provision saying that it can.
55. As set out in paragraph 16, the Regulations (section 20(1)) only allow the council’s adjudication to include its response to the panel’s recommendations. They do not permit the council to disagree with the panel’s findings. That is supported by the Guidance, which only refers to the council making a response to the Panel’s recommendations. This is presumably because the strength of the three-stage statutory process lies in its independence, its thoroughness, and its ability to hear from witnesses. It would not follow the principles of natural justice if a single council officer was empowered to overturn the final findings of that robust process.
56. The second AO disagreed with some of the Panel’s findings and overturned them. This was fault. The fault caused Miss X and her family frustration that the proper process was not followed, and put Miss X to time and trouble in that she felt compelled to escalate her complaint to the Ombudsman.
57. The second AO also disagreed with some of the Panel’s recommendations. This was not necessarily fault, in that a council is permitted to do so within the Regulations and Guidance. Acceptable reasons for doing so would include if the Council had already made the changes recommended by the Panel, or if the Council had good reasons to disagree with a Panel’s recommended financial remedy. However, the Guidance states that, where an adjudicator proposes to disagree with a stage three Panel’s recommendations, they should invite comment from all the Panel attendees, and provide their reasoning for their decisions. The second AO did neither of these things. This was fault, that caused Miss X and her family uncertainty about the Council’s reasons for its decisions. During my investigation, the Council has acknowledged it was at fault in this regard and has offered an apology for the injustice caused, which I welcome.

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Action

58. Within one month of my final decision, the Council has agreed to:
1. Issue a new stage three adjudication letter to Miss X, in which the Council should come to a new decision about the Panel’s recommendations, given that it must accept the Panel’s findings. If the Council disagrees with the Panel’s recommendations, it must first invite comment from the Panel attendees and provide its reasons for the disagreement;
2. Apologise to Miss X and her family, and make her a payment of £200 in relation to the injustice caused by its faults in the stage three adjudication. (This payment is recommended in addition to, not instead of, the payments totalling £1250 that the Council has already offered to Miss X and Y);
3. Clarify to relevant staff that they are not empowered to challenge the stage three Panel’s findings;
4. Remind relevant staff that, where they propose to disagree with a stage three Panel’s recommendations, they should invite comment from all the Panel attendees and provide full reasoning for their decisions; and
5. Amend the template for the stage three adjudication letter to remove the line: “this adjudication will set out whether the council agrees with the findings and conclusions of the investigation”.
59. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology I have recommended above.
60. The Council should provide us with evidence it has complied with the above actions.

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Decision

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

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Investigator's decision on behalf of the Ombudsman