Summary: Mr X complains about the Council’s handling of his complaints following child protection enquiries about his child. There was delay in the Council’s response to Mr X’s stage three complaint and completion of resulting recommendations. The Council has agreed to apologise and make a payment to Mr X for avoidable uncertainty and distress caused by its handling and the delay. While the Council appears to have completed the recommendations made during the complaints process, it was never able to achieve the outcomes Mr X was seeking.

The complaint

1. The complainant, whom I have called Mr X, complains about the Council’s handling of his complaints following child protection enquiries into his child, Child Y. Mr X complains the Council’s responses at stage two and three of the statutory complaints process were delayed. He says the Council has failed to adequately complete the recommendations made by the stage three panel and the deficiencies in the stage two complaint investigation remain unresolved. Mr X says the Council’s actions have caused considerable distress, uncertainty and frustration for him and his family. Mr X also says he has been put to unnecessary time and trouble chasing the Council for its delayed responses.

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The Ombudsman’s role and powers

2. We investigate complaints about councils and certain other bodies. We cannot investigate the actions of bodies such as the local health trust. (Local Government Act 1974, sections 25 and 34A, as amended)
3. We cannot investigate a complaint about the start of court action or what happened in court. (Local Government Act 1974, Schedule 5/5A, paragraph 1/3, as amended)
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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

6. I have spoken to Mr B and considered the information he provided in support of his complaint.
7. I have considered the information the Council has provided in response to my enquiries.
8. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Office for Standards in Education, Children’s Services and Skills (Ofsted), we will share this decision with Ofsted.
9. Mr X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Children’s Statutory Complaints Process

10. The law sets out a three-stage procedure for councils to follow when looking at complaints about children’s social care services. At stage two of this procedure, the Council appoints an Investigating Officer and an Independent Person (who is responsible for overseeing the investigation). If a complainant is unhappy with the outcome of the stage two investigation, they can ask for a stage three review. If a council has investigated something under this procedure, the Ombudsman would not normally re-investigate it unless he considers that investigation was flawed. However, he may look at whether a council properly considered the findings and recommendations of the independent investigation.

What happened

Background

11. Child Y, Mr X’s son, was born with health conditions that affected his ability to feed normally. As a result, Child Y spent a considerable amount of time in hospital since his birth in 2015. During Child Y’s hospital stays in 2016, the local hospital raised concerns about his care. The hospital suspected Child Y’s mother, Mrs X, might have been fabricating or inducing illness which it felt had led to Child Y requiring more medical treatment than necessary.
12. Between January and May 2017, Child Y spent time in a specialist children’s hospital on a strict feeding and monitoring regime. He also underwent surgery to help resolve some of the issues he had with digestion before being transferred back to the local hospital. At the end of May 2017, a staff member at the local hospital observed Mrs X covertly diluting one of Child Y’s feeds before leaving for a short family holiday. The hospital tested a further feed following Mrs X’s return from holiday and found this had also been diluted.
13. In late June 2017, Mrs X was arrested and questioned by police and the Council. The Council placed Mr and Mrs X’s two children on a child protection plan in Mr X’s care and Mrs X had to move out of the family home. Mrs X’s contact with both her children was supervised as part of the plan.
14. The Council applied to the court for a care order for both children and a two-week fact-finding hearing took place in early 2018. The Council sought to prove Mrs X had induced illness in Child Y by withholding nutrition, which resulted in his unnecessary and prolonged admission in hospital. In addition to diluting two of Child Y’s feeds, the Council, together with the lead paediatrician, alleged Mrs X had tampered with Child Y’s medical equipment and had either fabricated or exaggerated acute life threatening events and hypoglycaemic episodes. The Council made 17 separate allegations against Mrs X as the basis of their case for a care order.
15. The court heard from Council staff, as well as staff from the local and specialist children’s hospitals. The court also sought expert opinion from an independent paediatrician. Aside from Mrs X’s dilution of two of Child Y’s feeds, the court found there were organic and legitimate explanations for all the other issues with Child Y’s health. This was based on evidence and testimony provided by the specialist children’s hospital, which the local hospitals trust stated it was unaware of until the court hearing. The Council withdrew all but the two allegations of feed dilution against Mrs X and asked the court to confirm its request not to seek a care order. The court concluded by placing the matter back under child protection procedures with the Council. The Council concluded its involvement with Mr X’s family in August 2018.

Mr X’s complaint to the Council

Stage two

16. In July 2019, Mr X complained about the Council’s handling of the child protection case. The Council bypassed stage one of its complaint procedure given the complex nature of Mr X’s concerns.
17. The Council informed Mr X of the statutory timescales of dealing with his stage two complaint. It said it was unlikely the 25 working day timescale would be met in Mr X’s case and told him it would instead aim to respond by the 65 working day extended timescale, which would be 13 November 2019.
18. The stage two Investigating Officer (IO) confirmed Mr X’s statement of complaint, which set out the following 16 issues:
1. The Council failed to involve professionals from the specialist children’s hospital in the child protection process, which led to the belief Mrs X was guilty of Fabricated or Induced Illness (FII), the decision to arrest Mrs X, restrict her contact with both children and apply to court for care orders.
2. The Council failed to adequately challenge the local hospitals about their view that Mrs X was guilty of FII, without properly scrutinizing all available evidence.
3. There has been a failure of effective multi-agency working in this case.
4. Mrs X was treated as guilty from the outset. The Council were rude and dismissive when speaking to her and showed no interest in hearing her side. The Council believed the views held by the local hospital without question.
5. The Council treated Mr X as a suspect through its involvement. The Council ignored key evidence Mr X provided which may have resulted in the withdrawal of many of the allegations made against Mrs X in court.
6. Mrs X’s contact with Child Y was restricted to six hours per week. Mr X was prevented from supervising this contact, which caused unnecessary distress to Child Y.
7. Mr X and other family members were banned from being present when Child Y was fed, and limits were put on the number of family members that could visit Child Y. The Council unreasonably withdrew agreement to relax restriction following pressure from the local hospital. This caused unnecessary distress to Child Y.
8. The Council failed to call Mr X back to confirm he could give Child Y a bottle feed under medical supervision, despite promising to do so.
9. The Council failed to complete a chronology for the child protection investigation and instead relied on one created by the local hospital, which omitted reference to Child Y’s stay at the specialist children’s hospital, and the diagnoses made there.
10. The Council failed to take minutes of the meeting at which it decided to take legal proceedings.
11. The Council failed to check evidence presented to the Initial Child Protection Conference (ICPC) about Mr and Mrs X’s other son, Child Z, which said he had had more visits to the General Practitioner and Accident and Emergency in his first two years. A report from independent medical advisors showed Child Z had presented less frequently than the average child.
12. The Council failed to explain the categories of harm in relation to which a decision needed to be made at the ICPC.
13. At the Review Child Protection Conference (RCPC), no vote was taken in relation to Child Z, which the Chair of the Conference said highlighted a gap in the Council’s policy.
14. The Council failed to follow the recommendation or consider the views of any relevant specialist, such as the family court judge in interim hearings and the children’s guardian. The Council instead prefer to follow the views of the local hospitals, even though they were making recommendations beyond their remit.
15. The Council, as the lead agency, has failed to take responsibility for the child protection investigation, claiming the investigation was instead health-led.
16. The Council has failed to carry out a review of its management of the case following the outcome of the final court hearing, where all but two undisputed allegations (for feed dilution) out of 17 against Mrs X were withdrawn.
19. Mr and Mrs X were seeking the following outcomes to their complaints:

• A face-to-face apology from a senior manager;
• a review of practice to address failings and rectify these to prevent any other family from the same ordeal;
• for the Council to improve its multi-agency working in child protection cases;
• confirmation the gap in policy highlighted at the RCPC has now been addressed;
• why the Social Worker consulted the RCPC Chair about contact matters, when the Chair is independent and does not have a say in such matters;
• what learning opportunities arose from this case, as stated by the Social Worker, and what lessons have been learnt by the Council as a result;
• the Council to provide three-monthly updates on progress against any action plan drawn up in response to the recommendations of the stage two complaint report; and,
• financial redress for the distress caused by the Council’s failings in the management of this case.

20. The IO completed their investigation into Mr X’s complaint and submitted their report to the Council on 16 September 2018 – 24 working days from the date of receipt. The IO upheld two of Mr X’s complaints (points 8 and 13) and partially upheld point 11. All other complaint points were not upheld. The IO recommended the Council made apologies for points they upheld and partially upheld and asked the Council to consider a senior manager making the apology in a face-to-face meeting. The IO did not agree the other outcomes requested by Mr and Mrs X needed to be completed by the Council, because they had not upheld the points of complaint that related to these.
21. The Council sent its adjudication letter, together with the IO’s report, to Mr X on 5 November 2018. The Council’s adjudication letter confirmed its agreement with IO’s findings and recommendations. The Council explained it would address point 8 through induction and training modules with all staff, point 11 through refresher training on recording and statement writing and point 13 would be addressed by the Safeguarding Service and reported back to the Principal Social Worker. The Council offered for a senior manager to meet with Mr and Mrs X to provide a face-to-face apology.

Stage three

22. Mr X requested a stage three review of his complaints and provided details of his concerns to the Council on 5 December 2018. The Review Panel meeting was scheduled for 14 January 2019 and Mr X was invited to attend in person.
23. On 24 December 2018, the Council contacted Mr X to explained it had had to reschedule the Review Panel to 22 February 2019 because this was the first date when all attendees were available.
24. Mr X had asked the Review Panel to focus on points 1, 2, 3, 5, 7, 12 and 14 of his stage two complaints (as listed in paragraph in paragraph 17 above). The Review Panel completed its report on 25 February 2019.
25. The Review Panel’s report made the following observations about the stage two investigation:

• The IO’s report failed to cross-reference any evidence or documents provided by the family against information gather from the Council.
• The IO had not realised court documents were held on the Council’s system and had not viewed these.
• There were discrepancies in file records held by the Council, which had not been identified by the IO.
• 26 professionals had been referenced in the IO’s report but only three were interviewed and one provided written information.
• No attempts appeared to have been made to contact a social worker that had worked on the case but had since left the Council.
• The Panel agreed with Mr X’s view the IO should have requested interviews with relevant health staff, even if they might not have been willing to participate.
• The Panel felt Mr X’s expectations of the stage two investigation could have been better managed.
• There was no reference to the impact on the children in the IO’s report.
• The scope of the stage two investigation was too narrow.

26. The Review Panel maintained not upheld findings for complaints 1, 2 and 12. The Panel partially upheld complaints 3 and 5, and made no findings on complaints 7 and 14. The Panel agreed Mr and Mrs X should receive a face-to-face apology from the Council for the failings identified by the stage two investigation.
27. While Mr X had not raised this, the Council commented on complaint 16 and strongly recommended the Council commissioned an independent case review to consider all aspects of management of the case, with a focus on ensuring local safeguarding board procedures were followed.
28. The Council sent Mr X the Review Panel’s report on 12 March 2019. It confirmed agreement with the Panel’s findings. The Council confirmed it would seek to complete a multi-agency case review, inviting colleagues from the hospitals and health services to participate. The Council told Mr X the review would be facilitated by a senior manager at the Council, who was independent of the case. The Council committed to completing this review by the end of June 2019 and providing Mr X with a summary of the findings.
29. Mr X questioned the Council’s approach to the case review. He felt it should be overseen by someone independent of the Council, like a manager from a neighbouring council. Mr X also questioned why the Council’s response to the stage three review did not include comments on the partially upheld complaints.
30. The Council’s reply explained that it had invited all agencies involved to the case review but had since been informed the local health services were not willing to participate. The Council explained it would include all the complaint findings in Mr X’s case in the review. The Council sought to reassure Mr X that it was able to appoint a Senior Manager with no previous involvement in the case to oversee the case review.
31. Mr X continued to correspond with the Council about the scope of its case review between March and May 2019. He expressed concern the Council’s in-house case review was not in the spirit intended by the stage three Review Panel. He also raised concerns that the complexity of his family’s case warranted independent scrutiny. The Council maintained its view that its approach to the case review satisfied the Panel’s recommendation and it sought to reassure Mr X that while it did not intend to reinvestigate his complaints, the case review would include the findings made in his case.
32. The Council provided a copy of the case review to Mr X on 23 September 2019, which provided findings of a case review meeting conducted on 27 July 2019. The Council also sent Mr X a copy of its draft action plan for the learning points from the case review. The Council explained the case review was not intended to re-examine the complaints Mr X had originally made about the Council’s handling of his family’s case. The Council also invited Mr X and Mrs X to a meeting on 3 October 2019, so it could provide its face-to-face apology for the three upheld complaints.
33. Mr X told the Council he could not attend the meeting it had scheduled for 3 October. He expressed extreme disappointment with the Council’s case review. He felt it avoided the main issue about the difference of opinion between the local hospitals and the specialist children’s hospital, and how this was known in advance of the court hearing. Mr X was also disappointed the Council intended to apologise for the three upheld complaints. He wanted to know what the Council intended to do to address the two partially upheld complaints and the two complaints for which the Review Panel made no finding.
34. The Council responded to provide written apologies for the three upheld complaints. The Council explained its review had considered the difference of opinion between health services and examined how this was managed during the child protection process. The Council reiterated that key information from the specialist children’s hospital only came to light at the court hearing, which led to the Council withdrawing its care order application. The Council withdrew its offer to meet with Mr and Mrs X to apologise in person as it felt believed little more could be achieved by this.
35. Mr X escalated his complaint to the Ombudsman as he remained dissatisfied with the Council’s handling and responses.

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Analysis

36. The statutory complaints process for children social care does not include investigation of complaints about child protection. Where councils choose to use this process for child protection matters, they should adhere to the timescales and principles set out in the statutory guidance.

Delay

37. The Council told Mr X from the outset that it would take longer to respond to his stage two complaint. The Council provided its response within the longer 65 working days set out in the statutory complaints process. In my draft decision, I said it was unclear why it took the Council a further 35 working days to consider and provide its adjudication report to Mr X, particularly when it agreed with the IO’s findings and recommendations.
38. In response to this, the Council explained it had asked the IO to revise their report because it contained confidential information that was not relevant to the IO’s findings. The Council says the IO submitted their finalised report to the Council on 2 October 2018. It is disappointing the date of the IO’s report was not altered to show this later date of finalisation. The Council may wish to consider providing this feedback to the IO and the IP. The Council’s adjudication letter following the IO’s report was sent to Mr X on 5 November 2018, which was within the 65 working day timescale.
39. There was delay in the Council’s arrangements of the stage three Review Panel. This process should have been completed 30 working days from the date of Mr X’s review request. The Panel met 55 working days from the date of request.
40. The most significant delay occurred in the Council’s completion of the case review. The Council took three months beyond its own target date to provide the outcome of its review to Mr X. During this time, the Council did not update Mr X on its progress.
41. The delays at stage three and beyond were fault and caused prolonged uncertainty and frustration to Mr X. The Council has agreed to remedy the injustice caused to Mr X as set out in paragraph 48 below.

Issues with the complaints process and recommendations

42. There is no doubt of the distress and anguish caused to Mr X and his family by what happened with Child Y. I have read about the impact of this situation on Mr X, his wife, children and their extended family. I also understand Mr X’s desire to get answers about what might have gone wrong as a way of helping the family move on from the trauma they have suffered.
43. The Council has never been able to provide this to Mr X and his family. While the Council took the lead in the child protection case, it had to rely on the evidence and expert opinions of other professionals and agencies. It did so in good faith and the judge found the Council could not have reached the point of withdrawing its care order application and the bulk of its allegations against Mrs X until the court hearing. The judge also acknowledged how Mr X’s testimony had assisted in reaching this point.
44. While the Review Panel identified deficiencies in the stage two investigation, it did not consider these so significant as to order a reinvestigation of Mr X’s complaints at stage two. The Council’s unsuccessful attempt at engaging the local health services in its case review appears to reinforce the Panel’s view that the Council has never been in a position to get the answers Mr X was seeking about the differences in clinical opinion. The Council does not have the power or authority to force health services to engage in its complaint procedure or review process, nor sadly does the Ombudsman. I suspect this may be the only way Mr X might get the answers he seeks. Mr X may however wish to pursue his concerns through the complaint procedures within the relevant health services, or their respective ombudsman service.
45. The Council has not provided Mr and Mrs X with a face-to-face apology as the Review Panel recommended. Mr X wanted the Council to do more than apologise for the three upheld complaints and felt there was little point in having a face-to-face meeting if the Council was unwilling to address the partially upheld and no finding complaints. I do not find the Council at fault for its approach. In place of the face-to-face apology, it has issued a written apology for the upheld complaints and provided Mr X with details of the action it intended to take following its case review which focussed on the other aspects of the complaint investigation findings.
46. Mr X has provided me with evidence (obtained from the Council) which showed the Council Manager who facilitated the case review had some involvement in the progression of the child protection case. As the Council had informed Mr X the case review would be overseen by someone with no prior involvement, there was fault in the Council’s handling in this respect.
47. Mr X has told me how much faith he had placed in the promises made by the Council when it assured him there was sufficient senior staff available within the Council, that could oversee the case review, without having had prior involvement in the substantive child protection case. He says he and his family felt cheated and treated with contempt when the Council selected a senior manager that clearly had been involved in the Council’s case going to court.
48. The injustice caused to Mr X and his family by this fault was further distress and a negative impression about the sincerity of the assurances he received at the start of the review process. It was a simple point the Council should have done more to get right if it was to truly seek to restore some of Mr X’s faith in its handling of the matter. I have recommended a further remedy below to address the impact of this fault.
49. I am not however persuaded this fault leads me to recommending the Council undertakes a further review of the case. The purpose of the case review was to give the staff involved the opportunity to revisit case management and reflect on their practice, which has been done even if in a somewhat limited way. I say this because even if the Council had ensured the case review was overseen by a Manager with no prior involvement, this was unlikely to have met Mr X’s expectations of the review. Ultimately, Mr X was seeking for the review to address his main concern about the differences in clinical opinion and I have already explained why the Council was not a position to achieve this.

Agreed action

50. Within one month of the final decision, the Council has agreed to:

• apologise for delays in complaint handling as described in paragraphs 39 to 41 above; and,
• pay Mr X £400 in recognition of the injustice caused by the delay in complaint handling and the distress caused by the fault described in paragraphs 46 to 48 above.

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Final decision

51. I have completed my investigation and uphold Mr X’s complaint. Mr X has been caused an injustice by the actions of the Council. The Council has agreed to take action to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman