Summary: The Ombudsmen found fault by the Trust and Council with regards to the care and support they provided to a young person with autism and her family. The Ombudsmen also found fault by the Council in its handling of the Child Protection process in this case. The Council and Trust will apologise to the family and pay a financial remedy in recognition of the impact these events had on them. They will also review their procedures to prevent similar problems occurring in future.

The complaint

1. The complainants, who I will call Mr and Mrs K, are complaining about the care and support provided to their daughter, Child H, and the family as a whole, by Derby City Council (the Council) and Derbyshire Healthcare NHS Foundation Trust (the Trust) in 2016 and 2017. In summary, they complain that:

• The Trust and Council failed to provide support to the family when Child H was in crisis in June and July 2016.
• The Trust and Council pressured Child H to return to mainstream schooling without appropriate support in September 2016 and without involving them in discussions.
• The Council’s decision to place Child H on a Child Protection Plan in October 2016 was unsupported by the available evidence.
• A Council social worker failed to seek input from a specialist clinician as required by the Child Protection Plan.
• The Trust failed to refer Child H to a specialist dentist despite this being identified as an action during the child protection process.
• There was excessive and unnecessary delay by both the Trust and Council in responding to their complaint.

2. In the interests of brevity, I have not set the complaint out in its entirety here. Rather, this intended as a brief summary of Mr and Mrs K’s main concerns. However, I have addressed each point in more detail in the ‘analysis’ section below.

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The Ombudsmen’s role and powers

3. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
4. If it has, we may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
5. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

6. In reaching this final decision, I considered information provided by Mr and Mrs K and discussed the complaint with Mrs K. I also considered documents provided by the Council and Trust, including the care records. Furthermore, I took account of relevant legislation and guidance. In addition, I considered comments from all parties on my draft decision statement.
7. 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

Relevant legislation and guidance

Autistic Spectrum Disorder

8. Autistic Spectrum Disorder (ASD) is a developmental condition which affects the way a person communicates with others and perceives and makes sense of the world. People with autism have difficulty with social interaction, social communication and rigid and repetitive ways of thinking and behaving. They may also have other difficulties such as sensory sensitivity and anxiety.
9. In 2013, the National Institute for Health and Care Excellence (NICE) produced guidelines entitled Autism spectrum disorder in under 19s: support and management [CG170].
10. Section 1.1.3 of the guidelines sets out that the assessment, management and coordination of care for children and young people with autism should be provided through local specialist multidisciplinary teams.
11. Section 1.1.8 says health and social care professionals working with children and young people with autism should receive training in autism awareness and skills in managing autism. This should include training on:

• the nature and course of autism;
• the nature and course of challenging behaviour in children and young people with autism;
• recognition of common coexisting conditions (such as anxiety, depression and sleep problems);
• the impact of autism on the family (including siblings); and
• skills for communicating with a child or young person with autism.

Child safeguarding legislation

12. Under section 47 of the Children Act 1989, local authorities have a duty to investigate if there is reasonable cause to suspect that a child in their area is suffering, or is likely to suffer, significant harm.
13. These investigations are commonly known as ‘s47 enquiries’. This will involve an assessment of the child’s needs and the ability of those caring for the child to meet them.
14. If a local authority is satisfied a child is at risk of significant harm, it may convene an Initial Child Protection Conference (ICPC). This is a multi-agency meeting to discuss the child’s needs and decide what action is necessary to protect the child from harm.
15. If professionals are concerned that a child may be at risk of serious harm, they can place that child on a Child Protection Plan (CPP). This is a formal document intended to set out the child’s needs and those of the family. The CPP should also set out what work needs to be done to reduce the risk posed to the child, who will undertake this work and within what timeframe the work will be undertaken.
16. Alternatively, if professionals are satisfied a child is not at significant risk of harm, but needs extra support, they can instead decide to place that child on a Child In Need Plan. The plan will set out the additional support the child requires and how local services will provide this.

Key facts

17. In 2013, Child H’s school was referred for an assessment by a community paediatrician due to concerns about her behaviour and night-time incontinence. The paediatrician noted Child H presented as being anxious, angry and withdrawn with low self-esteem.
18. In April 2015, the Trust’s Child and Adolescent Mental Health Service (CAMHS) accepted a referral for Child H. However, the service had a waiting list at that time.
19. Child H and her family began to attend multidisciplinary meetings (known as Team Around the Family (TAF) meetings) to discuss their support needs. These involved representatives from the Council, CAMHS service and Child H’s school.
20. Child H also had an allocated mental health nurse from the CAMHS team (Nurse A) who she saw regularly.
21. In November 2015, Mr and Mrs K arranged a private assessment for Child H. This established a diagnosis of Autism Spectrum Disorder (ASD).
22. In December 2015, the Council allocated a social worker (Officer B) from its Multi Agency Team to work with the family.
23. In January 2016, Child H was seen by a CAMHS psychiatrist who prescribed medication to help her sleep.
24. The family continued to attend TAF meetings over the following months, and Nurse A and Officer B also visited them at home.
25. In May 2016, Mrs K reported that Child H was being bullied at school and was becoming increasingly distressed. TAF meetings that month heard that Child H’s attendance at school had declined.
26. In June 2016, Mrs K reported that Child H was now refusing to attend school altogether. Mrs K said Child H was becoming increasingly aggressive towards the family and had threatened suicide.
27. In July 2016, Mrs K and Child H attended hospital. Mrs K reported that Child H was becoming increasingly violent towards her siblings and continued to threaten suicide. Child H was admitted to hospital for assessment. This found there was no clinical reason for her to remain in hospital and she was discharged home.
28. Later that month, the case was allocated to a social worker from the Council’s children’s services team (Officer C). Officer C visited the family in August and September 2016 to complete a single assessment for Child H. She noted the strained relationship between Child H and Mr K.
29. The Council convened a safeguarding strategy meeting on 30 September 2016. The meeting agreed that the case met the threshold for s47 enquiries to be undertaken. The professionals involved, including representatives from the Council and police, felt Child H may be a victim of emotional abuse.
30. The Council held an Initial Child Protection Conference (ICPC) on 20 October 2016. The conference concluded that Child H was at risk of significant emotional harm and should be placed on a Child Protection Plan (CPP).
31. Shortly after this, the Council reallocated Child H’s case to another social worker (Officer D). Officer D completed a new single assessment for Child H.
32. On 9 January 2017, the Council convened a review conference. This found no evidence that Child H had been emotionally harmed in the intervening months. The conference agreed that Child H no longer met the threshold for a CPP and that she should instead be considered a Child In Need.

Analysis

Crisis support

33. Mr and Mrs K complain that the Trust and Council failed to provide the family with support when Child H was in crisis in June and July 2016.
34. Mrs K emailed various professionals involved in Child H’s care on 23 May 2016 to report that Child H had disclosed she was being bullied at school. She wrote that Child H had “not eaten today, feels sick and has a bad head…the anxiety is presenting itself physically and she is constantly breaking down saying she can’t cope.” Mrs K subsequently attended a meeting with the school to discuss this.
35. On 20 June 2016, Officer B wrote an email in support of an EHC plan for Child H. She noted that “[o]ver the last 6 months I have noted a deterioration in [Child H’s] emotional wellbeing.”
36. Officer B visited Child H on 29 June 2016. She found her to be tearful and low in mood. Officer B advised Mrs K she felt Child H was “very depressed”. Officer B noted Mrs K’s understanding that Nurse A would be arranging for antidepressant medication for Child H.
37. The following day, Mrs K sent a further email explaining that Child H had physically attacked them, harmed herself and was feeling suicidal. Mrs K said Child H had also threatened her siblings.
38. Officer B contacted Nurse A. She advised Child H “was in a terrible state”. Nurse A agreed to arrange a visit to Child H. She said “[w]e have looked at medication previously but need to not rush into this.”
39. Nurse A visited Child H on 1 July 2016. The visit appears to have focused on Child H’s anxiety about returning to school. The note of the meeting contains no reference to Child H’s low mood, self-harm or suicide threats.
40. Officer B visited Child H again on 6 July 2016. She noted Child H had a strained relationship with Mr K and his parents.
41. Mrs K contacted both Officer B on 8 July 2016. She said Child H had threatened suicide again, made cuts to her arm and attacked one of her siblings. Officer B advised Mrs K to contact CAMHS.
42. Mrs K spoke to a duty worker in the CAMHS team as Nurse A was on leave. The duty worker advised Mrs K to take Child H to hospital in the event of an emergency. He “agreed to explore further ways to support and get back to [Mrs K] later today.” There is no evidence in the case records of the duty worker contacting Mrs K following this call.
43. Officer B contacted the other professionals involved with Child H to request an urgent meeting. She also discussed the case with a senior manager, who advised her to visit Child H. She did so later that day. Officer B again noted that Child H was anxious about her relationship with Mr K and his parents.
44. Mrs K contacted Officer B on 14 July 2016 as she had not received a response from the CAMHS team. I was unable to locate a response from Officer B in the records.
45. Mrs K attended hospital with Child H on 24 July 2016. An assessment found Child H’s recent behaviour represented a risk to both herself and her family. She was admitted to hospital for further assessment.
46. The case notes show that, by early July 2016, Child H’s presentation had changed significantly. Professionals were aware that Child H had harmed herself, attacked members of her family and was threatening suicide. Furthermore, the notes reveal that Child H had made what Officer B described as “very serious disclosures” about her home and family situation during Officer B’s visit on 6 July 2016.
47. Mrs K made repeated requests for assistance during this period and in the following weeks. This included Mrs K’s contact with the CAMHS duty team on 14 July 2016, when an officer failed to call her back to discuss support options.
48. The case records show the family was in crisis at that time and that professionals were concerned about Child H’s welfare. I note officers from the Trust and Council continued to visit the family during this period. However, I found no evidence to suggest officers took substantive action to address the deteriorating situation. This is evidence of fault by the Trust and Council. The apparent lack of any significant care interventions during this period contributed to the family’s distress.

Autism support and training

49. Mr and Mrs K complain that professionals involved in Child H’s care were not appropriately trained to deal with young people with ASD. They say this meant communication with Child H was often inappropriate and ineffective.
50. The NICE guidelines for the support and management of children and young people were published in 2013. The guidelines say the assessment, management and coordination of care for children and young people with autism should be provided through local specialist multidisciplinary teams. The guidelines also emphasise the importance of ensuring health and social care professionals working with children and young people with Autism are appropriately trained.
51. The multiagency team that was initially supporting Child H was not an autism-specific service. However, the evidence provided by the Trust and Council shows Nurse A and Officer B had undergone appropriate Autism training.
52. The case records show Nurse A arranged Autism-specific interventions for Child H and her family. This included a sensory assessment and the introduction of medication to address Child H’s sleep problems. In addition, the records show Nurse A discussed strategies for managing and supporting Child H with Mrs K.
53. In my view, the evidence suggests professionals from the multiagency team were attempting to support Child H and her family with her ASD diagnosis, albeit I accept Mr and Mrs K did not find these interventions helpful. I find no fault by the Council or Trust in this regard.
54. In contrast, neither Officer C nor Officer D appear to have undergone any Autism training. This is a significant omission; particularly given both officers were allocated to the case to undertake comprehensive single assessments. I note Officer C did consult with health colleagues with regards to Child H’s diagnosis. Nevertheless, this is not an adequate substitute for appropriate training. This represents fault by the Council.
55. It is not possible to say exactly what impact this fault had on the quality of Officer C and Officer D’s contacts with the family. This is because the case notes represent only a limited record of each contact. However, there is evidence to suggest Child H and her family found their contact with these officers distressing.
56. I accept the nature of the safeguarding process means it is likely to cause some degree of distress to those involved, regardless of how sensitively it is handled. In my view though, the involvement of officers who were not appropriately trained to deal with Child H’s complex communication needs is likely to have caused additional distress.

Pressure to return to school

57. Mr and Mrs K complain that the Trust and Council pressured their daughter to return to mainstream schooling without appropriate support in September 2016. Mr and Mrs K say a social worker told Child H that they were “deluding” her and that there was no reason why she could not return to mainstream school. On one occasion, Mr and Mrs K says social workers discussed Child H returning to school without their knowledge. They say this failed to take into account Child H’s communication difficulties and caused her to become distressed.
58. The Council denied professionals pressured Child H to return to school. The Council said the officers working with Child H felt she was happy and excited about the prospect of returning to school. Nevertheless, the Council acknowledged social workers should have given more consideration to how such a discussion would impact on Child H.
59. The Trust said Nurse A discussed other possibilities with the family, such as a referral for out of school tuition.
60. On 17 March 2016, a TAF meeting discussed Child H’s attendance at school. The meeting heard Child H was occasionally refusing to attend school and complained of sickness. The meeting discussed changes to Child H’s morning routine to as a means of reducing her anxiety and supporting her attendance.
61. A subsequent TAF meeting in May 2016 noted that Child H’s attendance at school remained an issue. The meeting agreed that Nurse A would work with Child H to offer support around managing friendships and relationships.
62. On 23 May 2016, Mrs K informed the professionals involved in Child H’s care that Child H had reported she was being bullied at school. Mrs K remained in contact with Child H’s school about this over the following weeks.
63. On 20 June 2016, Officer B wrote to a colleague to support Child H’s application for an Education Health and Care (EHC) plan. She noted that Child H was no longer attending school. Officer B explained that Child H “feels that her needs are not being met at [the school] and this is having an effect in her life outside of school.”
64. This was discussed at a further TAF meeting later that month. The meeting agreed that Child H would meet with the school to discuss a plan for her return. However, shortly after this Mrs K reported that Child H was refusing to return to the school.
65. On 1 July 2016, Nurse A visited Child H. She noted Child H “wants to return to school as she is finding it hard not to be doing anything.” Nurse A also noted Child H had several concerns about the school. Child H explained that she found it difficult to cope with the number of people in the classroom as she found this distracting. She also said she found it difficult to cope with the fact that school meals changed daily.
66. Officer B accompanied Child H on a visit to the school on 8 July 2016. She noted that Child H appeared to have enjoyed the lesson she attended and spending some time with her friends.
67. It is unclear from the records whether Child H attended school again following this visit. The records show her behaviour was deteriorating and she was admitted to hospital briefly on 24 July 2016. Shortly after this, the case was allocated to Officer C to complete a single assessment.
68. Following Child H’s discharge from hospital, Nurse A visited her again on 29 July 2016. She noted that Child H “believe[s] that going back to school has made her on the edge and the stress and tension at home is not good”.
69. The records show Officer B discussed school again with child H during a visit on 10 August 2016. Child H reported that she “wasn’t managing” at the school.
70. On 5 September 2016, Nurse A visited Child H and Mrs K. She noted was worried about the prospect of returning to school. However, she noted Child H was similarly worried about remaining at home. Nurse A recorded that she had suggested CAMHS could support Child H to return to school or could alternatively arrange a referral for hospital schooling.
71. Mrs K was unhappy with this approach and complained that professionals were putting undue pressure on Child H to return to school.
72. A professionals meeting on 15 September 2016, which included representatives from the Trust, Council and school, agreed Child H would be able to return to her current school with support.
73. Officer B and Officer C visited Child H at home on 22 September 2016. Officer C noted that Child H “was bored and wanted to return to school”. She noted they had discussed a return to school and had looked at a copy of a school timetable. Officer C went on to record that Child H “became very enthusiastic at the prospect of returning to school and I explained this would need to be discussed with her parents and school first and I offered that I could support with this.” Officer B subsequently contacted the school to discuss the possibility of a return for Child H if Mr and Mrs K agreed. However, when Officer C returned Child H home, she noted that Mr K was not prepared to allow Child H to return to school without an EHC plan in place.
74. This prompted Mr and Mrs K to complain to the Council. They said that Child H had become extremely distressed following the discussion with Officer B and Officer C.
75. It is clear from the records that this was a complex case. The evidence shows there was a significant disparity between the views of Mr and Mrs K and the professionals involved in the case as to the extent of Child H’s needs. The case records seem to show that many of the professionals felt Child H would be able to return to mainstream school with a package of support.
76. In contrast, Mr and Mrs K felt Child H required an EHC plan before she could safely return. The EHC plan was still being prepared at the time of these events. Furthermore, Mr and Mrs K felt Child H would benefit from a specialist residential placement. This view was not shared by the professionals involved in her care.
77. This dispute was compounded as the evidence suggests Child H’s views and presentation on the matter were variable. At times, she appeared to professionals to be keen to return to school. At other times, she expressed anxiety about the prospect and stated that she felt the school could not support her.
78. It is important to note that, by September 2016, Child H had been attending school only sporadically, or not at all, for several months. In this context, it was appropriate for the professionals involved in the case to explore whether she could be supported to return to school.
79. Nevertheless, it is clear that Child H’s ASD diagnosis required professionals to carefully manage communication with her.
80. The Trust’s records show Nurse A worked with Child H to gain a clear understanding of her anxieties and concerns around returning to school. This is reflected in the note of Nurse A’s visit on 1 July 2016. I found no evidence in the records to suggest Nurse A placed undue pressure on Child H. I found no fault by the Trust in this regard, therefore.
81. Nurse A also discussed the matter with Mrs K during a visit on 5 September 2016. Nurse A noted “I explained the services we could offer to help [Child H] adjust back into mainstream and then after a block of time assess how she is managing.”
82. In my view, Nurse A should have done more to make clear what support the CAMHS team would be able to offer. I would have expected to see Nurse A agree a care plan with Child H and Mr and Mrs K that clearly set out Child H’s support needs and what would be done to meet them. I found no evidence in the records to suggest this was done. This is fault by the Trust and caused the family unnecessary confusion and frustration.
83. In addition, I have concerns about the handling of the visit to Child H by Officer B and Officer C on 22 September 2016.
84. I note the views of these officers that the discussion about school was led by Child H. I also recognise the importance of ensuring Child H was given an opportunity to present her views. In this context, it was appropriate for the officers to discuss how Child H felt about the possibility of returning to school.
85. In my view, it was equally important for the officers to involve Mr and Mrs K in any planning for Child H’s return to school. This would have been in keeping with the NICE guidelines for working with young people with autism, which emphasise the importance of a collaborative approach to treatment and care.
86. However, the notes of the visit show Officer B and Officer C instead engaged Child H in detailed planning for her return to school without the knowledge of Mr and Mrs K. This included reviewing her school timetable and selecting lessons she would like to attend. Indeed, Officer B even contacted the school to discuss whether it could accommodate a limited return for Child H.
87. I found no evidence to suggest Officer B or Officer C considered the potential impact of these discussions on Child H in the context of her diagnosis and associated communication difficulties. This is fault by the Council and caused distress for both Child H and Mr and Mrs K.

Child Protection Plan

88. Mr and Mrs K complain that the Council’s decision to place Child H on a CPP in October 2016 was unsupported by the available evidence. Mr and Mrs K say social workers failed to obtain important input from professionals involved in Child H’s care and that their reports contained inaccuracies and contradictions. Mr and Mrs K also say Officer C acted inappropriately by pressuring them to reveal information about Child H’s biological father. They say Officer C also posted sensitive documentation through their letterbox.
89. The Council said it did not make the decision to place Child H on a CPP in isolation. Rather, it said the professionals present at the ICPC, including representatives from health, education and the police, agreed the threshold had been met. The Council said the meeting had been chaired by an appropriately trained and independent manager.
90. The case records show Officer B recorded what she considered to be serious disclosures from Child H during a visit on 6 July 2016. In particular, Officer B noted that Child H had a difficult relationship with Mr K and his parents and felt bullied by them.
91. I am aware Mr and Mrs K are particularly concerned about some of the comments Officer B made to Child H during this conversation. I appreciate the record of this conversation would have been upsetting for them. Nevertheless, Officer B had a responsibility to safeguard Child H if she believed her to be at risk. This meant Officer B needed to gain a full understanding of Child H’s concerns.
92. The Department for Education produces guidance entitled Child abuse concerns: guide for practitioners. Section 28 of this guidance explains that the signs of abuse may not always be obvious and that a child might not tell anyone what is happening to them. The guidance goes on to say that a practitioner “should therefore question behaviours if something seems unusual and try to speak to the child, alone, if appropriate, to seek further information.”
93. The evidence shows Officer B was attempting to seek further information from Child H. I found no evidence to suggest Officer B placed undue pressure on Child H to make a disclosure. Indeed, Officer B’s note suggests most of the information she noted was volunteered by Child H.
94. Section 31 of the guidance says that a practitioner who has concerns about a child’s welfare should “discuss your concerns with your manager, a named or designated professional or a designated member of staff.”
95. Officer B discussed these disclosures with a manager from the children’s services team on 8 July 2016. Following this discussion, she recorded that “the level of [Child H’s] disclosures are not severe enough to warrant an escalation to [children’s services].”
96. Shortly after this, Mr and Mrs K wrote to the Council to request accommodation for Child H under s20 of the Children Act 1989. This is the section of the act which sets out local authorities’ duties with regards to accommodation for children in need. As a result, the children’s services team became involved. The case was allocated to Officer C in August 2016 to complete a single assessment.
97. As part of the single assessment, Officer C sought the views of other professionals involved in Child H’s care. This included Nurse A, Officer B, an educational psychologist and the school nurse from Child H’s school.
98. Officer C noted her view that Mr and Mrs K were exaggerating Child H’s difficulties to secure a residential school placement. She reported that Child H was at risk of significant emotional harm.
99. The Council convened a safeguarding strategy meeting on 30 September 2016. The meeting agreed the case met the threshold for s47 enquiries and that an ICPC would be necessary to discuss professional concerns.
100. The Derby and Derbyshire Safeguarding Children Partnership Procedures Manual (the Manual) states that “[l]ocal authority Children’s Social Care should explain the purpose and outcome of Section 47 enquiries to the parents and child/ren (having regard to age and understanding) and be prepared to answer questions openly, unless to do so would affect the safety and welfare of the child.”
101. I found no evidence in the case records to suggest Officer C explained to Mr and Mrs K that she was undertaking s47 enquiries. If Officer C believed this would place Child H at greater risk, this should have been clearly recorded in the case notes. However, I found no evidence this was done. In my view, Officer C did not act in accordance with the procedures set out in the Manual in this regard. This is fault by the Council.
102. Officer C shared her completed single assessment report with Mr and Mrs K on 7 October 2016. It appears Mr and Mrs K were informed on 12 October 2016 that an ICPC would take place.
103. The Council convened the ICPC on 20 October 2016. The professionals present agreed Child H should be subject to a Child Protection Plan. The CPP set out that:

• Social workers would continue to visit the family to work with Child H and would seek clinical input regarding her ASD diagnosis;
• The school nurse from Child H’s school would follow up any outstanding health appointments;
• Child H would attend an education placement (in line with any recommendations in her EHC plan, which had yet to be approved);
• The Council would contact and assess relevant family members if necessary; and
• Mr and Mrs K would not talk negatively about Child H in front of her.

104. The Manual sets out who should attend a child protection conference. This should be “only those people who have a significant contribution to make due to their knowledge of the child and family or their expertise to the case.”
105. It is unfortunate that neither Officer C nor Nurse A attended the ICPC. These were the practitioners with most the recent and relevant experience of the family. Nevertheless, the notes of the ICPC show other relevant staff did attend. This included Officer B, Officer C’s manager and a CAMHS manager. Representatives from Child H’s school and a youth centre she attended were also present. The meeting also considered Officer C’s assessment report, which contained both her views and those of Nurse A.
106. In their complaint to the Ombudsmen, Mr and Mrs K also raised concerns about Officer C’s assessment report. They said this contained significant inaccuracies. As an example, Mr and Mrs K said Officer C’s report speculated that Child H and her siblings may be victims of domestic violence, but that there was no evidence to support this claim.
107. I note Mr and Mrs K‘s comments. Given the nature of the allegations against them, it is understandable Mr and Mrs K did not share Officer C’s views with regards to the risk to Child H. It is also understandable that they found the report distressing.
108. Officer C had a responsibility to present her professional view on Child H’s situation, based on her contacts with the family. In preparing her assessment, Officer C also sought the views of other professionals involved with the family. She recorded the comments provided by these professionals in the case notes. Officer C’s report appears to accurately reflect these entries in the notes.
109. There is evidence to suggest Officer C did not place appropriate focus on the family’s strengths and those of Mr and Mrs K as parents. This was identified during the Council’s Stage 2 investigation.
110. Nevertheless, the evidence available at that time, including the case records and Officer C’s report, shows the professionals involved in Child H’s care shared concerns about her welfare. These appear to have related primarily to the disparity between the views of Mr and Mrs K and the professionals as to the extent of Child H’s needs and the fraught relationship between Child H and Mr K.
111. The notes of the ICPC also show that Mr and Mrs K were given an opportunity say why they felt Officer C’s report and recommendation was inaccurate. Mrs K’s comments are recorded in the notes.
112. It is not for the Ombudsmen to decide whether a child should be subject to a CPP. This is a matter of professional judgement for the officers involved. On balance, I am satisfied the professionals present at the ICPC had sufficient information available to make their decision. The notes of the meeting show that all professionals agreed with the decision to place Child H on a CPP at that time. I find no fault by the Council in this regard, albeit I understand Mr and Mrs K did not agree with this decision.

Officer C

113. Mr and Mrs K also complained about Officer C’s conduct during the single assessment process. They said Officer C behaved inappropriately in attempting to gather information about Child H’s biological father. Furthermore, Mr and Mrs K said Officer C did not discuss her report with them. They said Officer C simply posted the report through their letterbox, despite its sensitive contents.
114. The case records show that Officer C did ask Mrs K for further information about Child H’s extended family. This included her biological father and maternal grandparents. In my view, this was a necessary part of Officer C’s single assessment.
115. I understand Mrs K found this distressing. However, I am unable to comment on the tone of Officer C’s contacts with Mrs K or on any specific comments she made. This is because there is no independent evidence available that would allow me to establish what was said.
116. I note the Council did recognise this had been upsetting for Mrs K and apologised for this. This is a reasonable and proportionate response to this point.
117. With regards to the single assessment report, the case notes show Officer C called Mrs K twice on 7 October 2016. However, these calls were unsuccessful. Officer C sent Mrs K an email shortly afterwards. She explained she wanted to share her report and asked Mrs K to contact her. When Officer C did not hear back from Mrs K, she delivered the assessment report by hand later that afternoon. As Mr and Mrs K were not at home, Officer C posted the report through their letterbox.
118. Officer C had a duty to share her single assessment report with the family in advance of the ICPC unless she had reason to believe that to do so would place Child H at greater risk.
119. It is clear from the single assessment report that Officer C was aware of this responsibility. Indeed, she noted that “[t]he sharing of this assessment with [Mr and Mrs K] in my opinion may also place [Child H] at further risk of harm given the evidence already detailed within. This will need to be given due consideration.”
120. It is unclear from the case records whether Officer C did give this matter due consideration or why she felt it was appropriate to share the report. This was a potentially significant omission given Officer C’s comments above.
121. Furthermore, it is of concern, given the sensitive nature of the report, that Officer C chose to post this through the letterbox without first discussing it with the family. This increased the risk of the report being accessed by Child H or other members of the family. This represents fault by the Council.

Specialist clinical input

122. Mr and Mrs K complain that a Council social worker (Officer D) failed to liaise with an ASD-specialist educational psychologist as required by Child H’s CP. Mr and Mrs K say this meant the social worker’s communication with Child H was ineffective and that Child H would not engage with the process as a result.
123. The Council found Officer D attempted to contact the clinician before her sessions with Child H but that he was unable to provide guidance. Nevertheless, the Council acknowledged Officer D was “not tenacious enough” in pursuing support.
124. In October 2016, Mr and Mrs K submitted a complaint about Officer C’s handling of the case and the single assessment she had completed. They also subsequently complained about the handling of the ICPC.
125. The Council agreed to allocate the case to a new social worker to undertake a further single assessment. The case was allocated to Officer D on 10 November 2016.
126. The records show that, by this stage, the family’s relationship with the Council had deteriorated to such an extent that all contact was directed through Mr and Mrs K’s solicitor. It appears Officer D initially struggled to agree dates for her visits to the family.
127. On 29 November 2016, a core group meeting agreed that Officer D would be supported by an ASD-specialist clinician “so that the social worker has an understanding around ASD and the best way in which to communicate and interact with [Child H].” However, the meeting notes also recorded that “[t]here needs to be clarity on who this consultant is as it was not clear”.
128. On the same day, Officer D spoke to an educational psychologist. She noted “[d]iscussed my involvement and he shared that he had nothing to offer”. The educational psychologist advised Officer D to contact an educational psychologist who had previously been involved with Child H.
129. Later that day, Officer D contacted the other educational psychologist. As that clinician was the subject of a complaint from Mr and Mrs K, she declined to comment in detail.
130. On 5 December 2016, Officer D contacted the first educational psychologist again. She noted she had “been advised that you would be able to support me regarding my work with this child…I am due to see [Child H] and the family over the coming weeks to complete a single assessment and would value your input in any area that may support [Child H] and her needs”.
131. However, the educational psychologist replied to explain that Child H “needs support from a clinical psychologist to address her difficulties at home. We only deal with school issues.”
132. Officer D attended a core group meeting on 19 December 2016. It was noted that she would “have 1-2-1 sessions with [Child H] in and out of the home in order to complete the single assessment.” The notes of the meeting contain no discussion about the difficulty Officer D was encountering obtaining support from an appropriate clinician.
133. The records show Officer D continued to visit the family in the weeks leading up to the review conference on 7 January 2017. However, I found no evidence to suggest she made any further attempt to seek support during this period.
134. The core group meeting of 29 November 2016 clearly identified the need for Officer D to be supported by an appropriate clinician so that she “has an understanding around ASD and the best way in which to communicate and interact with [Child H].” This was to assist Officer D to build a relationship with Child H.
135. The evidence shows there was a lack of clarity around which clinician should provide this support. This caused confusion and meant that, when Officer D contacted two clinicians in November and December 2016, she was advised they could not assist her.
136. I also share the Council’s view that Officer D should have done more to resolve this situation. There is no evidence to suggest she raised this in supervision with her manager or at the subsequent core group meeting in December 2016. As a result, Officer D’s contact with the family continued without ASD-specialist input. This is fault by the Council. This was a potentially significant omission given Officer D did not have any specific training on working with children with Autism.
137. The evidence Child H presented to the review conference in January 2017 suggests she was unhappy with the interventions of the social workers involved in her care and the Child Protection process more generally. Child H commented that visits from the social workers generally made her angry or upset.
138. Based on the evidence available, I am unable to say whether additional support from an ASD-specialist clinician would have had a significant impact on the situation.
139. Nevertheless, the Council missed an opportunity to explore alternative approaches and techniques in the context of Child H’s autism diagnosis. This caused Child H, as well as Mr and Mrs K, unnecessary distress.

Dental referral

140. Mr and Mrs K complain that the Trust failed to refer Child H to an ASD specialist dentist despite this being identified as an action during the child protection process. Mr and Mrs K say this resulted in Child H developing gum disease, for which she is still receiving treatment.
141. The Trust acknowledged Mrs K had requested a dental referral for Child H. The Trust said it sent Mrs K an email asking her to attend to sign a form or, alternatively, to let it know if she wanted the form to be sent to her via email. The Trust said it was unable to say what the outcome of this message was.
142. The Council’s records suggest the dental referral was first discussed at a core group meeting on 1 December 2016. The notes of the meeting record “Mother to arrange a dentist appointment for [Child H] as this is outstanding.”
143. Mrs K said that, when she tried to arrange the appointment, she was advised that the CAMHS service would need to make a referral.
144. Mrs K subsequently emailed the CAMHS team on 20 December 2016 to request a referral.
145. Mrs K raised the matter again at the review child protection conference on 9 January 2017. The notes of the meeting show a member of the CAMHS team agreed to make a referral.
146. On 3 February 2017, the Trust wrote to Mrs K to ask her to complete a referral form. I found no evidence in the records to suggest the Trust followed this up.
147. Mrs K told me she completed the necessary form on more than one occasion but that the CAMHS team misplaced it. Again, I found no evidence in the records to corroborate this.
148. Nevertheless, it is not in dispute that the Trust failed to make a referral for Child H even though this had been agreed at the review conference on 9 January 2017. Indeed, the evidence I have seen suggests that it was not until Child H moved to a residential school placement in September 2017 that the necessary referral was made. This is fault by the Trust.
149. This caused Mr and Mrs K uncertainty as I am unable to say whether an earlier referral would have prevented Child H’s gum disease.

Complaint handling delays

150. Mr and Mrs K complained there was excessive and unnecessary delay by both the Trust and Council in responding to their complaint.
151. Mrs K initially complained to the Trust on 7 September 2016. However, the complaint was not passed to the complaints team until February 2017, over five months later. The Trust appointed an investigator shortly afterwards, but there was some further delay before the investigator was able to meet with Mr and Mrs K in April 2017. The Trust completed its investigation in July 2017 and wrote to Mrs K’s solicitor with the outcome. This meant the investigation took around three months.
152. Mr and Mrs K attended a meeting with the Trust in October 2017 to discuss their complaint. This led the Trust to provide a further response on 7 December 2017.
153. Mr and Mrs K remained dissatisfied with the response and the Trust agreed, in February 2018, to review the records and prepare a further response. Mr and Mrs K received the response in June 2018.
154. In my view, there is evidence of significant delay by the Trust in its handling of Mr and Mrs K’s complaint. In particular, there was a delay of around five months before the complaint was even passed to the complaints team for investigation. I found no satisfactory explanation for this delay. I consider this to be fault by the Trust. This caused Mr and Mrs K avoidable frustration.
155. Mr and Mrs K first complained to the Council in September 2016. They were unhappy with the Council’s Stage 1 response, which they received later that month. They requested a Stage 2 investigation.
156. Mr and Mrs K then raised further concerns about the handling of the Child Protection process in October 2016 and February 2017.
157. In March 2017, the Council confirmed it would investigate all matters at Stage 2. It agreed a formal statement of complaint with Mr and Mrs K in May 2017.
158. The investigating officer shared her report in November 2017. The Council responded to her findings in January 2018.
159. Mr and Mrs K attended a meeting with the Council in April 2018 and requested a further Stage 2 investigation.
160. It was not until a further meeting in October 2018 that the Council confirmed it did not intend to proceed with a further investigation.
161. I accept Mr and Mrs K’s complaint was complex. This meant the investigating officer had a considerable volume of case records to review. She was also required to interview several members of staff. Taking everything into account, I do not consider the time it took to complete the Stage 2 investigation (around six months) to have been excessive.
162. However, it is unclear why it took the Council so long (six months) to confirm that it was not prepared to undertake a further Stage 2 investigation. This constitutes undue delay. This is fault and caused Mr and Mrs K further frustration.

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Agreed actions

163. Within one month of my final decision statement, the Council will write a letter of apology to Mr and Mrs K and Child H. This should acknowledge:

• The Council’s failure to take substantive action to support the family when it was in crisis between May and July 2016.
• The Council’s appointment of officers to Child H’s case who were not appropriately trained to support a young person with Autism.
• The failure of Council officers to act in accordance with local child safeguarding policies and procedures (Derby and Derbyshire Safeguarding Children Partnership Procedures Manual).
• The Council’s failure to handle Mr and Mrs K’s complaint in a timely fashion in accordance with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.

164. In addition, the Council will pay £200 to Child H and £400 to Mr and Mrs K (a total of £600). This recognises the distress and frustration caused to them by the fault I have identified.
165. Within one month of my final decision statement, the Trust will write a letter of apology to Mr and Mrs K and Child H. This should acknowledge:

• The Trust’s failure to take substantive action to support the family when it was in crisis between May and July 2016.
• The Trust’s failure to make clear how the CAMHS service could support Child H’s return to school.
• The Trust’s failure to refer Child H to a specialist dentist as agreed during the Child Protection process.
• The Trust’s failure to handle Mr and Mrs K’s complaint in a timely fashion in accordance with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.

166. In addition, the Trust will pay £200 to Child H and £200 to Mr and Mrs K (a total of £400). This recognises the distress and frustration caused to them by the fault I have identified.
167. Within three months of my final decision statement, the Council and Trust will provide the Ombudsmen with a joint response explaining what action they will take to:

• Ensure there is a clear process of escalation within both the CAMHS team and Multiagency Team for children and young people determined to be in need of crisis support.
• Ensure appropriate specialist care is available for children and young people with Autism in the area. This should include information about what the Trust and Council will do to ensure staff are appropriately trained in supporting children and young people with Autism.
• Ensure relevant staff are appropriately trained in local and national safeguarding policy and procedures. This should recognise the importance of clearly documenting key decisions.
• Ensure there is robust procedure in place in the CAMHS team for making, and following up, referrals to allied health professionals where appropriate.
• Ensure complaints are handled in a timely fashion in accordance with the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. This should include a process for coordinating joint responses to complaints that involve both health and social care services.

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Final decision

168. I found fault by the Council and Trust with regards to the care and support they provided to Child H and her family.
169. In my view, the further actions the Council and Trust have agreed to undertake represent a reasonable and proportionate remedy for the injustice caused to the family by the fault I identified.
170. I have now completed my investigation on this basis.

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Parts of the complaint that I did not investigate

171. There was significant disagreement between Mr and Mrs K and the Council with regards to Child H’s needs and her EHC plan. There was further disagreement as to whether Child H required a specialist residential school placement.
172. Mr and Mrs K pursued these matters through the First-tier Tribunal (Special Educational Needs and Disability) and, ultimately, via Judicial Review. The Ombudsmen are unable to investigate matters for which a person has or had a right of appeal to a tribunal. Similarly, the Ombudsmen cannot investigate matters that have been subject to court proceedings.
173. For this reason, I did not investigate these aspects of Mr and Mrs K’s complaint.

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Investigator's decision on behalf of the Ombudsman