Summary: Ms X complained the Council failed to properly consider her complaint about its actions during an assessment of her children’s needs, which it investigated through the children’s statutory complaint procedure. The Council failed to respond to an identified risk, delayed in investigating Ms X’s complaint and failed to properly complete the children’s statutory complaint procedure. The Council has agreed to apologise to Ms X and pay her a total of £1000 to recognise the distress, frustration and time and trouble caused by the faults, and pay her son £200 to recognise the injustice he was caused.

The complaint

1. Ms X complained the Council failed to properly consider her complaint about its actions during an assessment of her children’s need, which it investigated through the children’s statutory complaint procedure. Ms X stated:
• the Council did not uphold two elements of her complaint despite the panel advising it to do so;
• did not consider parts of her complaint at stage three when it agreed to do so at stage two; and
• did not offer appropriate remedies to recognise the injustice caused by the elements of her complaint it did uphold.
2. Ms X stated this caused her frustration, depression and anxiety.

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The Ombudsman’s role and powers

3. The Information Commissioner's Office considers complaints about freedom of information and data protection. Its decision notices may be appealed to the First Tier Tribunal (Information Rights). So, where we receive complaints about information handling, we normally consider it reasonable to expect the person to refer the matter to the Information Commissioner.
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. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
6. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
7. 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.

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How I considered this complaint

8. I considered the documents provided by Ms X and discussed the complaint with her on the telephone.
9. I read the documents provided by the Council.
10. Ms 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

Safeguarding enquiries

11. Section 47 of the Children Act 1989 sets out a council’s 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. They must decide whether they should take any action to safeguard or promote the child’s welfare.
12. Where a child’s need is relatively low level, individual services and universal services may be able to take swift action. Where there are more complex needs, the council may offer a service under section 17 (child in need) or section 47 (child protection) of the Children Act 1989.
13. Section 17 says councils must safeguard and promote the welfare of children within their area who are in need. A child is in need if:

• they are unlikely to achieve or maintain a reasonable standard of health or development unless the council provides support;
• their health or development is likely to be significantly impaired unless the council provides support; or
• they are disabled.

14. Where the council’s children’s social care decides to provide services under section 17, it should develop a multiagency child in need (CIN) plan which sets out which organisations will provide which services to the child and family. (Working Together to Safeguard Children)
15. The Public Law Outline (PLO) process takes place when a council is concerned about a child's wellbeing. The council may consider making an application to the Court for a Care or Supervision Order for the child.

Statutory complaints procedures

16. The law sets out a three-stage procedure for councils to follow when looking at complaints about children’s social care services. The accompanying statutory guidance, ‘Getting the Best from Complaints’, explains councils’ responsibilities in more detail.
17. The first stage of the procedure is local resolution. Councils have up to 20 working days to respond. Where the Council accepts a complaint at stage 1, it is obliged to ensure the complaint continues to stage 2 and 3 if that is the complainant’s wish.
18. If a complainant is not happy with a council’s stage one response, they can ask it to consider it at stage two. At this stage councils appoint an investigator and an independent person who oversees the investigation. Councils have up to 13 weeks to complete stage two of the process from the date of request.
19. If a complainant is unhappy with the result of the stage two investigation, they can ask for a stage three review by an independent panel. The council must hold the panel within 30 days of the request and issue a final response within 20 days of the panel hearing.
20. The guidance states if the Council intends to deviate from the panel’s recommendations it should invite comment from all the attendees, including the independent person appointed at stage two. It should provide its reasoning for deviating in its response to the complainant.
21. The complainant can withdraw their complaint at any time. The Council must write to the complainant to confirm withdrawing the complaint.
22. If a council has investigated something under the children’s statutory complaint process, the Ombudsman would not normally re-investigate it unless we consider the investigation was flawed. However, we may look at whether a council properly considered the findings and recommendations of the independent investigation.

What happened

Council’s involvement with the family

23. In November 2018 Ms X lived at home with Mr T and their son G and daughter L. In the middle of November, the Council received four safeguarding referrals for G because he was reported as missing and causing damage at home. The referrals raised concerns about G’s safety and risk to his family members.
24. The Council held a strategy meeting and decided to complete an assessment of need for both G and L. To complete the assessment Social Worker A met with all members of the family and spoke with other professional services to gather information. The assessment resulted in CIN plans for both G and L starting in December 2018.
25. The Council developed a safety plan to ensure everyone knew their responsibilities and actions in keeping G and L safe. The Council decided the plan would be for G and not necessary for L.
26. The CIN plan was in place until June 2019 after which the Council closed the CIN case and began supporting the family through the Early Help service.

Self-harm

27. During November 2018 Social Worker A conducted several visits to all members of the family to conduct the assessment. She spoke to them alone and together.
28. During the assessment period G caused an injury by self-harming and was admitted to hospital. The hospital record showed that G caused the injury on Day 1 although it was not discovered until Day 3.
29. The assessment record shows Social Worker A visited G in his bedroom on Day 2, before his injury was known. There is no contemporaneous record of that visit or what they discussed. At the time Ms X and Mr T could not access G’s bedroom due to his behaviour.
30. On Day 3 Social Worker A emailed G’s school and said she had been in G’s bedroom the previous day and there was ‘a lot of tissue with a lot of fresh blood on’. Social Worker A told the school she had told Ms X. She also said she would make a Children and Adolescent Mental Health Service (CAMHS) referral for G due to his behaviour and the significant self-harm.
31. In the evening of Day 3 G attended the hospital and said he had self-harmed on Day 1. He was admitted to hospital for assessment of his injury and mental health.
32. The case notes show that Social Worker A visited G at home on Day 4 after he was discharged from hospital. Social Worker A recorded that G allowed her to remove his cutting blade from the bedroom during that visit.
33. On Day 5 the Council held a meeting with the professionals involved with G, and his parents. After the meeting Social Worker A emailed Ms X and Mr T. She said she had seen bloodied sheets and blood stains on the carpet in G’s room the previous day.
34. Ms X told us Social Worker A did not speak to her about any blood in G’s room on Day 2 and so she was not aware of G’s injury.
35. In response to my enquiries the Council stated it did not have a record of Social Worker A making a CAMHS referral for G.

Complaint

Stage 1

36. In June 2019 Ms X complained to the Council. She raised several points about the Council’s actions during the assessment of the family’s needs. Ms X said Social Worker A had seen blood stains in G’s bedroom and had not told her. As a result, there was a delay in G receiving medical care for a self-harm wound. Ms X also said Social Worker A had threatened to take G in to care.
37. In July 2019 the Council responded to Ms X’s complaint. The Council said it had interviewed Social Worker A and she reported that she had seen ‘a bloody tissue’ and had told Ms X. However, the Council confirmed there was no record of that conversation. It said it was not clear from the records whether Social Worker A had told Ms X of the bloodstains when she saw them.
38. Regarding the threat of care proceedings, the Council said Social Worker A explained what may happen if circumstances did not change. It said the Social Worker’s use of the word ‘removed’ in the assessment was unhelpful. The letter said if Ms X was dissatisfied with the response she could contact the complaints team. It did not refer Ms X to stage 2 of the complaints process.
39. Ms X responded to the Council later that month. She said she did not agree with the Council’s findings about the bloodstains in G’s room. She said Social Worker A had made multiple verbal threats to take the children in to care.
40. The Council discussed the matter with Ms X on the phone the following day.
41. In July 2019 Ms X made a subject access request (SAR) to the Council to see the information it held about her and her children.
42. There was further correspondence and meetings between Ms X and the Council from July 2019 until February 2020.
43. In September the Council sent Ms X a further complaint response letter. It said Social Worker A should have had a clear conversation with Ms X about the bloodstains in G’s room and that had not happened. It stated the reference to a PLO process in the original safety plan and the reference that G may be ‘removed from his parents care’ was not appropriate. The Council apologised for both matters. It asked Ms X to contact it if she would like to discuss the matter further. It did not mention stage 2 of the complaint procedure.
44. The Council provided Ms X with its response to her SAR in December 2019.
45. In February 2020 the Council told Ms X it had reached the end of stage 1 and Ms X had received all the information the Council could provide from her SAR. It stated if she remained dissatisfied, she should contact the Council explaining her complaint and desired outcomes.

Stage 2

46. In March 2020 Ms X sent her stage 2 complaint to the Council. Ms X complained the Council had not properly investigated her complaint about the threats of care proceedings, or the failure to act about the blood in G’s room. Ms X also complained about how the Council had handled her SAR.
47. The Council appointed an Investigating Officer and an Independent Person. In April the Investigator agreed a statement of complaint with Ms X which had 8 points of complaint including the matters outlined in paragraph 46.
48. In August 2020 the Investigator finished his investigation. It upheld one complaint, partially upheld four and did not uphold three complaints. It found that:
• the Council did not get consent from G, L or their parents to gather and share information about G or L;
• the Council did not share the assessment with the family before it signed it off and did not include their comments;
• the rules that Social Worker A put in place for G during the assessment period were inappropriate and resulted in G being at further risk of harm;
• documents were missing from the SAR sent to Ms X and it had not sent the email retention policy when Ms X requested it; and
• there were a number of statements made by Council Officers in documents that were not well phrased or explained.
49. The investigation did not uphold Ms X’s complaint that Social Worker A had repeatedly threatened taking the children in to care. It commented that miswording in documents and poor explanation by Social Worker A may have caused the impression the children may be removed.
50. It did not uphold Ms X’s complaint that Social Worker A had failed to act after seeing blood in G’s bedroom, as she had reported it twice in that week.
51. The Investigation recommended the Council make service improvements:
• amended procedures to ensure assessment reports are sent to families before being signed off, and that family’s comments are included in final reports;
• develop training for staff about writing style to ensure reports were not unnecessarily critical or implied criticism; and
• respond to Ms X’s request to substantiate, remove or contextualize records about her family.
52. The Council considered the Investigator’s report and wrote to Ms X in September 2020. It agreed with the findings of the stage 2 investigation. It apologised for the upheld complaints and the distress they caused. It explained what service improvements it had made. It asked Ms X to tell it the information she would like to have amended so it could consider it.
53. Ms X remained dissatisfied and at the end of September she asked it to consider her complaint at stage 3.
54. Ms X told me the Council contacted her a week before the stage 3 panel hearing. It advised her the SAR complaint was not appropriate for the children’s statutory complaint process and she should use the corporate complaint route instead.

Stage 3

55. In December the Council convened a stage 3 panel with independent panel members. The records show the panel decided one point of complaint was not appropriate to consider as it related to information handling. It said Ms X should direct this to the corporate complaint route.
56. The Panel agreed with two of the Investigator’s findings. The panel decided:
• one complaint that was partially upheld should be amended to upheld;
• two complaints that were not upheld should be upheld.
57. The panel said the investigation found all four members of the family felt they had been threatened with G and L being taken in to care. It said that element of Ms X’s complaint should be upheld.
58. The panel found Social Worker A had failed to take prompt and appropriate action about the blood in G’s room. It said that element of Ms X’s complaint should be upheld.
59. The Panel recommended:
• the Council should provide compensation for the upheld complaints, and should consider compensation for Ms X’s time and trouble in pursuing the complaint;
• Ms X should seek to have the records amended through the ICO with her SAR complaint;
• The Council should remind staff of the need to get full written consent, and that self-harming should be considered a safeguarding issue and dealt with appropriately; and
• Staff should be reminded of the Home Office guidance ‘adolescent to Parent Violence and Abuse’.
60. The Council considered the Panel’s recommendations and sent Ms X an adjudication letter at the end of December 2020. It said it agreed with most of the Panel’s findings. It said it had reviewed the interview conducted with Social Worker A at stage 1, stage 2 and the case notes. It did not agree Social Worker A had ignored blood in G’s room. The Council said it would review how it recorded such incidents.
61. The adjudication letter apologised that the family felt threatened that G and L may be taken in to care. However, it did not agree with the Panel’s finding as it did not believe there was evidence the social worker repeatedly threatened the family.
62. The Council offered a payment of £100 to recognise the time and trouble Ms X took in bringing the complaint and a further £300 for the distress and frustration caused by the upheld complaints.

Further information

63. Dissatisfied with the Council response Ms X complained to us. Ms X provided a copy of the notes she made during the professionals meeting in November 2018. She recorded: ‘[Social Worker A] has told [G], [L] can go into care’.
64. Ms X provided a copy of a note made by L following a meeting with Social Worker A in November 2018. It stated: ‘said we could go into care’.
65. Ms X confirmed that she later raised her complaint about the SAR and information handling matters through the Council’s corporate complaints process. She confirmed she had taken the matter to the ICO.
66. Ms X said that because G’s injury had already begun to heal when he was seen at hospital, it could not be stitched. As a result, he has a significant scar.
67. In response to my enquiries the Council said it did not discuss its intention to deviate from the Panel’s recommendations with the Independent Person, before it issued the adjudication letter to Ms X.
68. The Council said it considered the SAR complaint at stage 2 as it was inextricably linked to the other matters complained about. After stage 2 it felt it had nothing to add on that point. As it could then separate it from the other complaints it directed Ms X to the ICO. It stated it was not appropriate for the panel to consider the information handling at stage 3.

My findings

Delay

69. Ms X began her complaint with the Council in June 2019. The Council did not progress the complaint to stage 2 until February 2020 despite it being clear that Ms X was not satisfied with the Council responses at stage 1. Although the Council engaged in significant meetings and correspondence with Ms X, it did not provide her with information about progressing to stage 2. It took 150 days longer than the guidance allows to complete stage 1. It took a further 100 days to provide Ms X with a response at stage 2, which is 45 days longer than the guidance allows. It delayed a further 14 days in completing the stage 3 panel, and two days in providing the stage 3 adjudication letter. The overall delay of 211 days was fault and caused Ms X frustration and time and trouble in pursuing her complaint. The Council has already offered Ms X £100, however that is inadequate to remedy the injustice the delays caused.

Self-harm

70. The Council investigation changed its finding on this matter at each stage of the complaints process. I have reviewed the documents available about this complaint and the threats of the children being taken into care.
71. There are discrepancies in Social Worker A’s account, there are no contemporaneous notes of the event and Ms X is clear she was not told about the blood. It is likely Ms X would have sought treatment for the injury had she known about it earlier. Therefore, on the balance of probabilities Social Worker A did not tell G’s parents about the blood she had seen in G’s room on Day 2. That was fault.
72. In her email to school on Day 3 Social Worker A stated she saw lots of blood on lots of tissue. She believed G had caused significant harm and she was going to make a CAMHS referral. This was a significant injury and Social Worker A should have made a record on G’s case file at the earliest opportunity. There is no record of Social Worker A making a CAMHS referral. All of this is fault.
73. Social Worker A removed the cutting blade from G on day 4. However, I have seen no evidence that Social Worker A took any action about the significant risk she perceived G to be at on Day 2. That was fault.
74. The failure to tell Ms X about the blood and take appropriate action resulted in a missed opportunity to get G timely medical care for a significant injury which Ms X says has left G with a permanent scar.

Threats of care

75. The initial assessment referred to G being removed and, separately, care proceedings (PLO). The stage 2 investigation found there was miswording in documents and poor explanation by Social Worker A. Ms X and L both have contemporaneous notes from separate meetings recording Social Worker A told them G and L could go into care. Mr T and G both said they felt threatened with care during separate meetings. On the balance of probabilities, Social Worker A used poorly phrased words about care proceedings in her conversations and recordings. That was fault and caused the family to feel threatened and caused distress.

The complaint process

76. The elements the Council removed from the complaint process related to Ms X’s SAR and information handling matters. The ICO is the appropriate body to consider complaints about those matters and Ms X has already contacted it. As such I have not investigated these matters any further, other than how the Council considered them within the children’s statutory complaint procedure.
77. The Council accepted Ms X’s complaint at stage 1 of the statutory complaints process and confirmed it at the beginning of the stage 2 investigation. The guidance states it was obliged to ensure the complaint progressed through all stages of the complaint procedure. It did not and that was fault. This caused Ms X further frustration and additional time and trouble of having to complain through the corporate complaint procedure.
78. The Adjudicating Officer did not invite comment from all the attendees, including the Independent Person appointed at stage two, when they considered the Panel’s recommendations and the Council’s response. This was particularly relevant given the investigation’s findings changed between each stage of the complaint procedure, and the Adjudicating Officer was deviating from the Panel’s recommendations. That was not in line with the statutory guidance and was fault. It leaves Ms X with uncertainty about what the Council’s adjudication would have been had it followed the correct process.

Council’s remedy

79. In addition to the remedy it offered Ms X for time and trouble, the Council has apologised to Ms X about the complaints it upheld and offered her £300 to recognise the distress it caused. This was not a sufficient remedy for the distress and frustration caused to Ms X by the faults identified during stage two and three of the complaints process. The Council has not offered a remedy for the further risk of harm G was placed at in line with our guidance on remedies, although there is no evidence to suggest he suffered harm at that time.

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Agreed action

80. Within one month of this decision the Council will:
• apologise to Ms X for the distress and frustration caused to her by the faults identified during my investigation outlined in the ‘my findings’ section above;
• pay Ms X £600 to recognise the distress, frustration and uncertainty she suffered because of the faults identified at stage 2 and 3 and during this investigation;
• pay Ms X £400 to recognise the time and trouble and frustration caused to her by the delays in completing the children’s statutory complaint procedure and the corporate procedure; and
• pay Ms X £200 to recognise the additional risk G was placed at and the missed opportunity to seek earlier medical attention. Ms X should use the money for G's benefit as she sees fit.
81. The Council will provide us with evidence that it has done so.
82. Within one month of this decision the Council will provide us with evidence it completed the service improvements identified at stage 2, namely:
• amended procedures to ensure assessment reports are sent to families before being signed off, and that family’s comments are included in final reports; and
• develop training for staff about writing style to ensure reports were not unnecessarily critical or implied criticism.
83. Within two months of this decision the Council will:
• produce letter templates for use within the statutory complaint procedure. These should set out the timescale for the current stage of the process and the complainant’s right to progress to the next stage at the conclusion of that stage;
• remind relevant staff of the guidance on the conduct of children’s statutory complaints procedures, with particular reference to adhering to timescales;
• share the findings of this investigation with all relevant departments including children’s services, the data protection office and legal services;
• ensure relevant departments consider whether officers should deal with complaints about the data handling alongside substantive matters where they are linked.
84. The Council will provide us with evidence it has done so.

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Final decision

85. I have completed my investigation. I found fault leading to injustice and the Council agreed to my recommendations to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman