Summary: We do not find fault in the Council’s investigation of Miss Y’s complaint about child protection proceedings for her children, C and D. We do not uphold the points of complaint which Miss Y continues to dispute because they have been subject to a thorough and independent investigation. While the Council has already implemented most of the agreed outcomes, we find the Council should take the lead on one outstanding point. We also consider the existing remedy does not go far enough in providing redress for the personal injustice experienced by Miss Y and her family and the Council has agreed to pay £500 in recognition of this.

The complaint

1. The complainant, whom I will call Miss Y, complains about the conclusions reached during the investigation into her complaint about the Council’s decision to begin child protection proceedings in 2019.
2. Miss Y says the outcomes agreed during the complaint investigation do not go far enough in providing a suitable remedy for the significant injustice her family experienced. Miss Y also complains some of the agreed outcomes have not yet been implemented.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), 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. During my investigation I discussed the complaint with Miss Y by telephone and considered the information she sent to me by email.
7. I made enquiries of the Council and considered its response. When doing so, I also consulted the relevant law and guidance which is cited where necessary in this statement.
8. I issued my draft decision to the Council and Miss Y and invited their comments. I considered any comments received before making a final decision.

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What I found

Complaints under the statutory procedure

9. Section 26(3) of the Children Act (1989) says all functions of the Council under Part 3 of the Act may form the subject of a complaint under the statutory complaints procedure.
10. Complaint investigations under the statutory procedure consist of three stages:
• Stage 1: Staff within the service area complained about try to resolve the complaint.
• Stage 2: An Investigating Officer (IO) and an Independent Person (IP) investigate the complaint. The IO writes a report which includes details of findings, conclusions and outcomes against each point of complaint (i.e. “upheld” or “not upheld”) and any recommendations to remedy injustice to the complainant.
• Once the IO has finished the report, a senior manager should act as adjudicating officer. They will consider the complaints, the IO’s findings, conclusions, and recommendations, as well as any report from the IP, and the complainant’s desired outcomes. The adjudicating officer should write to the complainant with their decision on each complaint (Department for Education and Skills 2006 Getting the best from complaints: Social Care Complaints and Representations for Children, Young People and Others).
• Stage 3: A review panel considers the complaint. The panel must consist of three independent people. Following the panel, the members write a report containing a brief summary of the representations and their recommendations for resolution of the issues (The Children Act 1989 Representations Procedure (England) Regulations 2006 19(2)).
11. The council must send its response to the panel’s recommendations to the complainant within 15 days of receiving the panel’s report. The response should set out how the council will respond to the recommendations and what action it will take. If the council deviates from the panel’s recommendations it should explain its reasoning in the response (Department for Education and Skills 2006 Getting the best from complaints: Social Care Complaints and Representations for Children, Young People and Others).
12. Unless there is evidence of fault in the investigation process, the Ombudsman will not usually re-investigate a complaint which has been through the full procedure. This is because a properly conducted investigation is independent and robust. The regulations specify the IO appointed by the Council should be independent. They may be an employee of the Council but should have had no involvement with the subject matter of the complaint. To ensure impartiality, the process is also overseen by an IP, who is neither an elected member or an employee. The Ombudsman would rely on the findings made unless we find flaws in the process.

Background of key events

13. Miss Y has two primary school aged children, who I will refer to as C and D. In June 2019 C and D’s school made a referral to the Council regarding concerns it had about an altercation between Miss Y’s partner, whom I will call Mr W, and Miss Y’s brother. The altercation happened in the presence of C and D. There is a history of domestic abuse between Miss Y and Mr W.
14. Following this, Miss Y left the family home with C and D. The Council decided to begin enquiries under S47 of the Children’s Act to establish whether C and D were at risk of harm. Two social workers visited Miss Y and later concluded that Miss Y may not be able to make informed judgements about Mr W following a previous injury and the impact this had on her memory.
15. The Council proceeded to a Children and Family (CAF) assessment to fully assess the risk to C and D.
16. Three weeks later, the Council began its enquiries. The social worker visited Mr W, C and D’s father and interviewed Miss Y’s brother by telephone. The following week the social worker also visited Miss Y and briefly saw C and D.
17. Miss Y went on a pre-planned holiday with C and D. Mr W travelled at the same time as the family but stayed in accommodation which was 30 minutes from Miss Y and the children. Miss Y says they only met up on five occasions and ensured that C and D’s contact with Mr W was limited.
18. In August 2019 the Council finished its CAF assessment, which said the Council would have serious concerns about C and D’s emotional wellbeing should Miss Y continue having contact with Mr W. The Council said it would consider whether C and D would be better supported by a Child Protection plan.
19. When Miss Y returned from holiday, both social workers visited Miss Y and her children. The social workers spoke with C and D alone. C said she had seen Mr W nearly every day during the holiday and this had impacted on her enjoyment of the holiday. Miss Y said they had only seen Mr W on five occasions.
20. The Council’s case recordings say that a social worker talked to Miss Y about the contents of the CAF assessment and explained the Council may need to progress the case to an Initial Child Protection Conference (ICPC). Miss Y disputes this conversation took place.
21. The Council held an Initial Strategy Discussion on 21 August 2019. It decided the level of emotional risk to C and D was too high due to Miss Y’s continued contact with Mr W. The Council therefore decided to complete a further CAF assessment and move the case to an ICPC.
22. The Council held the ICPC on 3 September 2019. The record of the ICPC notes that D had recently spent time with Mr W at a football match. The Council made C and D subject to Child Protection plans.
23. The school which employs Miss Y said it would need to seek advice about her employment due to concerns it had about the implications of her memory loss.
24. Dissatisfied with how the Council handled the case, Miss Y made a formal complaint under the statutory childrens complaints procedure.
25. Shortly after issuing the first stage response to Miss Y’s complaint, the Council held a Review Child Protection Conference (RCPC) on 9 December 2019. The Council decided to maintain C and D’s plan to be reviewed again in three months.

The complaint investigation

26. At the first stage of the complaint procedure, Miss Y made 21 heads of complaint. I will not revisit them all in detail here, but instead focus on the findings which Miss Y disagrees with.
27. The Council upheld one complaint regarding the accuracy of the social worker report. It conceded the report contained typographical errors, but on the whole found that it was clear and well-articulated.
28. The Council did not uphold the other 20 complaints, but did agree to pursue an outstanding referral regarding services for child D. The Council also apologised if Miss Y felt that support services were not effective, and said it hoped to resolve matters moving forward.
29. Dissatisfied with the response, Miss Y complained at the second stage of the statutory childrens complaints procedure. The Council appointed an Investigating Officer (IO) who met with Miss Y on 16 December 2019 to discuss her complaint.
30. The IO shared a draft copy of the proposed terms of reference with Miss Y. This contained 25 heads of complaint. Miss Y suggested some amendments, which the IO agreed. The IO met with Miss Y again on 2 January and visited the Council offices on 8 January to review the necessary case records.
31. On 1 May 2020 the IO submitted a draft version of their stage two complaint report to the Council. The IO then issued their final version on 15 June.

Stage 2 Upheld complaints

32. The IO upheld several of Miss Y’s complaints, which I will summarise below:
1. Miss Y did not have the opportunity to see or discuss the Council’s assessment before its completion, and her comments were not included or considered in the analysis and recommendation sections. Although the social worker claims to have shared the report with Miss Y during a visit in August, there is no evidence of this.
2. Social workers communicated in an inconsistent and confusing manner about Mr W’s ability to have contact with C and D following the school’s referral. The IO could not determine whether social workers were inconsistent and provided differing advice to Miss Y and Mr W, however the IO felt they should have been more explicit with Miss Y regarding their views and a written agreement regarding contact could have been produced before the holiday.
3. The Council’s decision to convene an ICPC following the family holiday was unfair and disproportionate. Miss Y says the Council was aware there would be some contact with Mr W during the holiday, with appropriate safeguards in place. The IO found the Council should have undertaken more assessment work before deciding to hold an ICPC. The Council could have explored a possible Chin In Need (CIN) plan and worked with Miss Y on a voluntary basis.
4. Miss Y says she was not informed by the Council that it had arranged an ICPC. The IO found a record of a written invite on the Council’s system, but Miss Y says she did not receive this. The IO concluded the social workers failed in their responsibility to ensure Miss Y was prepared for the meeting.
5. The Council did not provide a copy of the social work report until 15 minutes before the ICPC. Miss Y said this was not in accordance with procedures which state that reports must be provided at least two working days before the ICPC. The Council conceded, and the IO upheld the complaint.
6. Miss Y said she was not informed about the appeal procedure for Child Protection Meetings. The IO interviewed the Chair, who acknowledged that Miss Y was not provided with the necessary information.
7. Miss Y said the Stage 1 complaint response did not address her concerns about the wishes and feelings of D and that social workers did not acknowledge D’s wish to maintain contact with Mr W. The IO concluded the decision to prevent contact until the risk assessment of Mr W had taken place was disproportionate. The IO said social workers could have taken a more ‘flexible and responsive’ approach to ensure D and Mr W had safe contact.
8. Miss Y complained that D was prevented from having contact with Mr W’s parents, who posed no harm. As above, the IO found again the Council could have done more to ensure D had contact with Mr W’s parents.
9. Miss Y said that information within C’s plan was misleading and damaging because it implied that Miss Y was not honest. The IO found the disputed wording was unclear and potentially negative, and that social workers should have agreed more positive wording with Miss Y.

Stage 2 not upheld complaints

33. The IO did not uphold the following complaints which I have summarised below:
1. The Council failed to properly record the referral received from C and D’s school, and wrongly concluded that C had been pushed down the stairs. The IO visited the school and interviewed the relevant staff. The IO was satisfied the Council’s records accurately reflected the information provided by the school in the referral. There was no fault by the Council, and the CAF assessment made clear that C was not pushed as initially claimed.
2. The Council did not discuss the contents of the referral with Miss Y at the beginning of the CAF assessment. This would have allowed Miss Y to verify the accuracy and challenge any apparent errors. The IO reviewed the records and found the social workers discussed the referral with Miss Y at the appropriate time and made attempts to verify the accuracy of the referral.
3. The Council did not follow correct procedure when completing the CAF assessment because it did not complete a ‘brief assessment’ and share with Miss Y within ten days. Furthermore, Miss Y complained the assessment process was not completed within the required 45 days. The IO concluded that current guidance states the requirement for one single assessment. The deadline fell during Miss Y’s family holiday, and the social workers shared the assessment soon after her return.
4. Miss Y said the Council failed to implement a voluntary CIN plan during the assessment. The IO found the CIN was not procedurally required and would not have benefited C and D.
5. The Council did not offer any services to help address the relationship between C and Mr W, and disregarded the proposals made by Miss Y. The IO found records showing that Miss Y made clear her intention to keep any future relationship with Mr W separate from C. On the balance of probabilities, the IO concluded that Miss Y did not ask for support in this area.
6. The Chair of the ICPC suggested that C and D may be removed and placed with their father if Miss Y maintained contact with Mr W. The IO found the ‘Conference Outline Plan’ contained information about C and D’s father’s agreement to care for them if Miss Y could not safeguard them. The IO interviewed the Chair, who confirmed these comments were made in the context of a safety plan. The IO concluded this was a valid area of discussion.
7. Miss Y complained the Chair failed to attend a planned meeting with C which caused her distress. The Chair acknowledged the meeting did not go ahead due to illness, and that C’s advocate agreed to relay the message. The IO concluded the Chair was not responsible for C not receiving the message.
8. Miss Y says she was prevented from returning to work, as planned, due to false and misleading information about her health discussed with the Local Authority Designated Officer (LADO). The IO found the social workers did not provide false or misleading information, and that it was not appropriate for the IO to discuss decisions made within the Allegations Management Meeting.
9. Miss Y said the Council failed to provide D with appropriate and ‘autism friendly’ services which in turn raised his anxiety levels. The IO found that social workers consulted with D’s school for advice about appropriate communication methods. The IO did not find the work undertaken was harmful to D.
10. Miss Y complained that social workers were not mindful that D struggles with unannounced visits to school. The IO interviewed the social worker who said that visits to D’s school were not unannounced, and D always expected their visits. The deputy head teacher said D was usually happy to meet with social workers.
11. Miss Y said that social workers misreported C’s views and wrongly told the school that C did not want school staff present during social worker visits. The IO considered comments from the social workers, C’s school and the ICPC Chair and found there was a difference of perception, but that C had told the Chair she wanted the Deputy Head present during a visit.

Stage 2 partial or inconclusive findings

34. The IO could not reach a finding, or made a partial conclusion, in the complaints which I have summarised below:
1. Parts of the social work assessment report presented to the ICPC in September 2019 were either factually incorrect, misleading or without context. The IO partially upheld the complaint because they found the Council could have expressed parts of the report in a clearer way and with more evidence. The IO also found the report lacked proper quality checks and contained unnecessary information about Miss Y’s childhood. The IO however felt the report did present an accurate picture of the social worker’s concerns and included sufficient information about C and D.
2. The Council did not give sufficient regard to Miss Y’s ability to prioritise the needs of C and D, and the Council did not consider the true wishes and feelings of C and D. The IO found the CAF report contained sufficient detail about work completed with C and D, however it failed to properly explore the reasons behind any negative feelings which C had towards Mr W.
3. Miss Y says information provided by the Council about a ‘brain injury’ was inaccurate and without context. Miss Y says she was not given the opportunity to verify or challenge the information and she offered to provide medical reports to support her views. The IO did not uphold this part of the complaint because the social worker shared information in an appropriate way, relayed Miss Y’s own account and gave her the opportunity to provide information at the meeting. The IO could not reach a finding about the social workers’ apparent refusal to accept medical documents from Miss Y.
4. Miss Y said D was prevented from receiving support from Children and Adolescent Mental Health Services (CAMHSS) while he was subject to proceedings. The IO found the CP plan did not prevent CAMHS involvement, but that CAMHS had wished for D to have a period of stability before they assessed him. However, the IO upheld the other element of Miss Y’s complaint because the Council delayed in pursuing a referral to the Children’s Health and Disability team (CHAD) and did not give enough focus to D’s behavioural issues.
5. Miss Y complained that social workers did not recognise C’s anxieties about their visits and failed to keep to their proposed pattern of visits. The IO found that social worker visits were not frequent but found conflicting information about cancelled visits and so could not reach a finding.

Recommended outcomes

35. The IO made the following recommendations following their investigation:
1. The Council should begin work on a multi-agency plan to address D’s needs. This support should be implemented “as soon as is feasible” and should not be delayed by any further assessments.
2. The Council should consider undertaking a new, revised assessment which fully includes Miss Y’s views. Any future plans should be holistic and reflect both C and D’s needs.
3. A senior manager should meet with Miss Y to discuss the information about her childhood which was wrongly included in the CAF report. The Council should place a clear addendum on the file to indicate this information should not have been included and will not be shared. The Council should consider writing to Miss Y to assure her the information would not be disclosed to any third parties in the event of a Subject Access Request (SAR).
4. The Council should apologise to Miss Y for all complaints which have been upheld and partially upheld.
5. The Council should remind staff of the importance od ensuring that parents receive copies of social work reports three days before an ICPC.
6. The Council should remind social workers of the importance of properly and contemporaneously recording all contacts with families in the electronic care records.
36. The Independent Person (IP) agreed with the findings and recommendations made by the IO and found the investigation was “detailed and thorough”.

Adjudication and Stage 3

37. The Stage 2 adjudication, issued to Miss Y from the Head of Service (HoS) on 26 June 2020, concluded the IO’s investigation was “robust and thoroughly researched”.
38. However, the HoS disagreed with the IO’s finding as summarised in paragraph 32 b) of this statement and said, “I do not agree that the threshold of evidence was met to conclude the social workers communicated in a very poor and confusing manner regarding the contact issues”. But the HoS agreed that a written agreement would have been “beneficial prior to the holiday”.
39. The adjudication letter also disputed the IO’s findings summarised in paragraph 32 c) because, “concerns could have been explored by further assessment… I do not accept that the decision to convene an ICPC was unfair and disproportionate”.
40. The HoS agreed with all other findings and the outcomes recommended by the IO. The letter concluded with the following:
• D is now having contact with Mr W and progress has been made regarding support services and an Education, Health and Care Plan (EHCP).
• An invitation to meet with Miss Y and discuss the areas of concern within the CAF report and arrange for an addendum to be placed on file.
• A full apology to Miss Y for the mistakes and subsequent distress.
• Several points of action for training and procedural improvements agreed with the social work teams.
41. Dissatisfied with the response, Miss Y asked for a Stage 3 review of her complaint. The review panel took place over two days: 14 and 24 September 2020 and Miss Y received the decision on 1 October 2020. The S3 Panel concluded:
• Records show that social workers were consistent in communicating their views about contact with Mr W. Miss Y should have been in no doubt about the Council’s view of any contact with Mr W during the holiday. The panel decided to change the finding of 32 b) to ‘not upheld’ but agreed it is desirable for social workers to provide clear written guidance outlining any possible outcomes.
• An ICPC is a multi-agency forum for sharing information about children from a range of professionals. The ICPC considered the views of C and D’s father and their school. The panel felt the decision to call an ICPC was based on the information available at the time, which indicated the threshold for concern was met. The social worker’s skill is to judge when an ICPC is necessary, and their decision was justified in this case. The panel decided to change the finding of 32 c) to ‘not upheld’ because it was not wrong to call an ICPC.
• The panel agreed with all other findings made by the IO, but made some extra recommendations to fully remedy Miss Y’s complaint:
1. Where social workers have concerns about a child and know the parent is taking a significant decision affecting that child, they should consider the benefit of a letter or a written statement to confirm the options and possible outcomes.
2. Managers should ensure there is a system of checks so parents receive reports for ICPCs in ‘good time’ before the conference, and to ensure social workers are available to go through the reports with parents.
3. When a child is causing concern because of their behaviour or mental health, social workers should support and guide the parent to access necessary services, while keeping a “watch on events and intervening when appropriate.”
4. Significant reports made by social workers should, wherever possible, receive checks under a quality assurance scheme for spelling and grammatical errors, as well as accuracy and context.
42. The Council issued its final response to Miss Y’s complaint on 20 October 2020. In summary, the Director accepted the panel’s findings and said:
• They support the panel’s recommendation for written agreements, where necessary, and social workers will be reminded of this requirement.
• They apologise further for the Council’s failure to help Miss Y prepare for the ICPC.
• The decision to hold an ICPC is a matter of professional judgement which is discussed with the team manager and other colleagues. The panel’s findings hopefully provide an in-depth explanation why this complaint was not upheld.
• The Council has prepared a reminder of the guidance around ICPC responsibilities, and the Chair now completes a quality assurance form after each conference. This records information about the timeliness and quality of the report.
• Team managers will attend a session on improving quality assurance checks to ensure reports are of a high quality and consistency across the service.
• They apologise for the added anxiety and stress caused to the family following the Council’s inaction in arranging support for D.
• The Council has recently introduced a new method of supervision which ensures a more structured approach to managing risks and improves the way in which officers support families.

The Ombudsman’s analysis

43. Part of Miss Y’s complaint to the Ombudsman is the Council either delayed, or failed, to fulfil all the outcomes agreed during the complaint investigation. The Ombudsman may find the Council at fault if we consider that remedial action was not implemented at the appropriate time.
44. One of Miss Y’s main areas of concern was the delayed provision for D. The IO made clear in their report that any necessary services should be provided without delay. I have considered the timeliness of any subsequent referrals and the provision of service. In response to my enquiries, the Council advises that it referred D’s case to CHAD in April 2020. I have not seen evidence of the referral, although it is mentioned in the Council’s adjudication letter of June 2020. I have also seen internal email exchanges, as provided to me by Miss Y following her SAR, which show some discussion in September 2020 about D’s CHAD assessment. I am therefore satisfied the necessary referral was made, although at a pace which Miss Y is dissatisfied with.
45. I am mindful that, upon assessment, D was found to be ineligible for CHAD services. Therefore, any alleged delay would have little direct impact on D because the delay did not hinder any subsequent services. I am also mindful that Miss Y is now pursuing a separate complaint about the CHAD decision and so it would not be appropriate for me to comment. Miss Y should await the result of that investigation.
46. The Council has explained that D now receives specialist educational provision following the completion of his EHCP. He is also supported through the Early Help (EH) plan and receives funding for short-breaks and Direct Payments for 12 hours of support each week, and an extra eight hours support each week during school holidays. The December 2020 CAF assessment also confirms that C continues to receive therapy from CAMHS.
47. Based on the information seen, I am satisfied the Council has already apologised to Miss Y and arranged for the necessary training and service improvements to take place.
48. However, there is one remedy point which remains outstanding. The IO said the Council should apologise to Miss Y and make a written assurance about the unnecessary inclusion in the report of information about her childhood. The Council has met with Miss Y and advised her that, due to data protection laws, it would not release the information to anyone else. The IO said the Council should also place an addendum on the file to make clear the information about Miss Y should not have been included and will not be shared.
49. In response to my enquiries, the Council said it is waiting for Miss Y to draft suitable wording for the addendum. When I spoke to Miss Y about this, she said the Council wanted her to go back through the files and, in her own words, make a record of the parts which she disputes. The Council would then use this as the basis of its addendum. Miss Y tells me that due to her work and family commitments she does not have the time to do this.
50. While the Council may be taking this approach to allow Miss Y to have control over the wording of the addendum, I share Miss Y’s concerns about how time consuming this could be for her, and I am also mindful it could cause Miss Y additional anxiety and stress. To remedy this, the Council will undertake the actions listed at the end of this statement.
51. I have also considered Miss Y’s concerns about the amendment of complaint findings for 32 b) and 32 c) (or complaints seven and ten, as they appear in the IO’s report). Miss Y explained to me that she was shocked and disappointed to see the adjudicating officer and the Stage 3 panel changed both findings to not upheld. I understand why this would cause concern, especially given the significance of complaint 32 c).
52. However, both the panel and adjudicating officer are entitled to reach their own view on the complaint. They may deviate from the IO’s findings but should clearly explain any reasons for doing so and set out their decision-making. Having considered the panel’s report, and the adjudicating officer’s letter to Miss Y, I am satisfied that any deviations from the IO’s findings have been clearly explained and reasoned.
53. I appreciate Miss Y would like the Ombudsman to overturn the ‘not upheld’ decisions, in particular for the two complaints in question. However, our role is not to reinvestigate the issues and apply our own findings, but to consider how the Council reached its decision. I find no fault with the decision making in this case; the investigation followed due procedure and considered information from a range of sources. I have no basis to criticise the eventual findings.
54. With that said, I consider some of the differing views about Miss Y’s complaint ten (or 32c in this statement) could have been avoided. This is because the different views may originate from the complaint wording. To comment on the “fairness” of something is subjective. The decision to call an ICPC is based on professional judgement, rather than fairness. In my view it would have been better to confine the investigation to objective facts such as whether the Council missed an opportunity to draw up a CIN plan before the ICPC.
55. Miss Y had made clear throughout the complaint investigation that her aim is to ensure that C and D are appropriately supported, and to bring about positive changes so that other families do not have the same negative experiences. While I have not upheld any more points of Miss Y’s complaint, it is my view the remedy already offered by the Council does not go far enough in resolving some of the significant personal injustice which Miss Y, C and D experienced from the fault identified. Although Miss Y has made clear that her intention is not to seek financial redress, I consider the Council should offer the remedy I have set out below. If Miss Y chooses to accept it, she may wish to purchase something for her family, or put towards a family holiday.

Agreed action

56. Within four weeks of my final decision, the Council will:
• Draft the addendum as recommended by the IO. The Council will use the IO’s report as the basis for highlighting the records which Miss Y disagrees with. Once the draft is completed, the Council will share a copy with Miss Y and invite her to comment. If Miss Y has no comments to make within the deadline specified by the Council, the Council will proceed with placing the addendum on the file; and
• Pay £500 to Miss Y for the distress which her family experienced following the faults identified in the IO’s report, as summarised in this statement.

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Final decision

57. We have completed our investigation with a finding of fault causing injustice.The remedial action already implemented by the Council, along with the agreed actions listed above, provide an appropriate remedy for the injustice caused by fault.

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Investigator's decision on behalf of the Ombudsman