Summary: Miss X complained about the Council’s actions and decision in relation to her daughter, F’s care in 2020 when she was discharged from a mental health hospital. The Council has upheld Miss X’s complaints after investigating them under the statutory children’s complaints procedure. It agreed to pay Miss X and F £250 each to acknowledge the distress and uncertainty caused by poor placement planning upon F’s discharge. It agreed to pay Miss X a further £500 to acknowledge the significant delays in completing stage 2 of the complaints procedure.

The complaint

1. Miss X complained about the Council’s actions and decision in relation to her daughter, F’s care in 2020 when she was discharged from a mental health hospital. Miss X says poor planning and the poor condition of the accommodation she was discharged to contributed to her readmission to hospital.
2. Miss X says the Council has investigated her complaint under the statutory children’s complaints procedure but she is unhappy with the outcome.

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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. 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)
5. 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

6. I spoke to Miss X about her complaint and considered information she provided.
7. I considered the investigation records and the investigation reports and adjudication letters from the children’s statutory complaints procedure in relation to Miss X’s complaint.
8. Miss X and the Council had the opportunity to comment on the draft decision. I considered comments before I made a final decision.

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What I found

Relevant law and guidance

Children’s statutory complaints 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. Councils have up to 20 working days to respond.
• 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 (ie “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. Councils have up to 13 weeks to complete stage two of the process from the date of request.

• Stage 3: A review panel considers the complaint. 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)). The council must hold the panel within 30 days of the date of request, and then issue a final response within 20 days of the panel hearing.
3. 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. However, we may look at whether a council properly considered the findings and recommendations of the independent investigation.

Unregulated care support placements

12. Prior to September 2021 the law and the Council’s guidance allowed children under 16 years of age to be placed in an unregulated placement in exceptional circumstances. Unregulated means the placement is not registered with Ofsted.
13. In September 2021 the law changed which meant placing children under 16 in unregulated placements was unlawful. These changes also put in place additional guidance for 16 and 17 year olds in supported accommodation which required social workers to undertake visits to assess the suitability of the unregulated placement.
14. As of October 2023 all providers of unregulated accommodation must register with Ofsted to be inspected by April 2024.

Care placement planning

15. Every child who is looked after by a council must have a placement plan which sets out day to day arrangements for the care of the child. The placement plan must be completed before a child is placed in accommodation. The placement plan forms the overarching care plan for the child. It should include arrangements for contact between the child and anyone with parental responsibility and arrangements for their health and any other support they require.
16. Children who are accommodated after staying in a Mental Health hospital are discharged under a multi-agency support plan as part of the Mental Health Act. This is usually referred to as Section 117 after care. Care placement should be discussed as part of this multi-agency approach.

What happened

Background

17. The following will provide a summary of the key events relevant to this complaint. It will not include every detail of what happened.
18. Miss X has a daughter, F who in 2020 was 16 years of age. F has a long history of involvement with the Council and was first looked after by it in 2017. F has a history of mental health issues which have resulted in moving placement multiple times and periods where she went missing.
19. In February 2020 F was sectioned under the Mental Health Act and moved to a hospital in another council area (council B) for a mental health assessment.
20. On 9 April 2020 the hospital discharged F to an unregulated semi-independent placement (Accommodation 1) in the Council’s area. Records show the hospital had reservations about F being discharged to accommodation near her parents, including Miss X. This placement broke down within 24 hours of F living there. F briefly went back home with Miss X. However this did not work out and resulted in police attendance. F returned to the mental health hospital on 11 April 2020.

Miss X’s complaint

21. Miss X first complained to the Council in February 2020 while F was in hospital. She had complained the Council had not kept her informed about F’s wellbeing. The Council responded to Miss X in March 2020 and explained F was an inpatient at the mental health hospital and the hospital had advised Miss X not to contact F while she was receiving treatment. The Council explained it would decide the most appropriate setting and support for F, once all assessments had been completed.
22. Following F’s discharge from hospital Miss X complained to the Council in April 2020 about the circumstances and handling of F’s discharge from the hospital, in particular the placement at Accommodation 1. However the Council failed to respond to her. Miss X chased the matter in January 2021 and following this the Council agreed to investigate Miss X’s complaint under the statutory children’s complaints procedure. The Investigating officer (IO) completed their report in November 2021. Miss X had made four complaints and the outcomes were as follows:
• Complaint 1 – Miss X was unhappy with the timing of F’s placement at Accommodation 1 over Easter which contributed to her readmission to hospital and let to a breakdown in the relationship between her and F. The IO upheld this complaint. They found it was unclear why the Council moved F to Accommodation 1 in the way it did. The IO found the placement was rushed, had a lack of proper planning and it was difficult to understand why F was placed in an unregulated placement.
• Complaint 2 – Miss X was unhappy with the condition of Accommodation 1 which she said was in poor condition, not managed properly and failed to manage F’s medication. The IO upheld part of this complaint and not other elements. It found there was not sufficient evidence to show it was in poor condition, but found the placement did not offer medication management as part of its service. Therefore, it found Accommodation 1 did not meet F’s needs.
• Complaint 3 – Poor communication from social services around F’s discharge. Miss X said the Council’s out of hours team failed to answer her calls following the breakdown of F’s placement at Accommodation 1. The IO did not uphold Miss X’s complaint about poor communication however it found it failed to properly respond to Miss X’s complaint in April 2020.
• Complaint 4 – Miss X says her role as a parent was ignored. The IO was unable to reach a conclusion. It found F had expressed views that she did not wish the Council to inform Miss X about her welfare. However, it found communication around F’s discharge and placement planning was inconsistent.
23. The Council wrote to Miss X with its adjudication letter in January 2022. It apologised for the delays in investigating the matter. It broadly accepted the IO’s findings. It offered Miss X £200 to acknowledge the time and trouble she had suffered complaining. It said it was working with partners and the NHS to provide a better service for young people leaving mental health hospitals.
24. Miss X was unhappy with the outcome of the stage 2 investigation and asked the Council to progress the matter to stage 3. The stage 3 panel considered Miss X’s request but found the stage 2 investigation was inadequate in relation to complaints 1 and 2. This was because the IO had failed to interview relevant professionals, specifically those that dealt with F at the hospital and the support workers from Accommodation 1.
25. A second IO produced a stage 2 addendum report which they completed in June 2022. They found the following:
• Complaint 1 – The IO upheld Miss X’s complaint that F’s move to Accommodation 1 was rushed and the placement was not ready. They said it would have been beneficial to wait until after the Easter weekend which would have given professionals more time to explore suitability of Accommodation 1.
• Complaint 2 – The IO found that although Accommodation 1 was sparsely furnished there was no evidence it was in poor condition. The IO did have concerns that workmen were present and some work was not complete. They found F was at Accommodation 1 for less than 24 hours so it was unclear how subsequent contact and visits would have been managed. The IO partly upheld complaint 2.
26. The Council wrote to Miss X with its further stage 2 adjudication letter in July 2022. It apologised for the delays which were caused by the requirement to carry out the addendum report. It accepted the IO’s findings. The adjudication officer made a further offer of £500 (£250 each for F and Miss X) in recognition of the distress caused by the poor planning of F’s discharge. It reiterated the £200 offer for the delays in investigating the complaint.
27. Miss X remained unhappy and asked to escalate the matter to stage 3. The stage 3 panel considered Miss X’s complaints at a meeting in August 2022. The panel made the following findings.
• Complaint 1 – upheld (no change from stage 2). The panel acknowledged it would have been in F’s best interests to slow the process down but said the responsibility lay with all professionals and not just the Council.
• Complaint 2 – the panel believed Miss X’s concerns about the poor condition of Accommodation 1 and the management of F’s medication was a result of poor planning. It upheld this complaint.
• Complaint 3 – The panel said there is evidence the Council did try and make contact with Miss X via its out of hours service. In addition social workers attended Miss X’s home to offer support. It made no change to the stage 2 findings around poor complaint handling.
• Complaint 4 – The panel found the Council did not adequately involve Miss X in the placement planning for F, despite her being entitled to information. It upheld this complaint.
28. The Council wrote to Miss X with its stage 3 adjudication letter at the end of August 2022. The adjudicating officer summed up the findings which were:
• Plans not robust enough for such a sudden change of placement for F
• Discharge should have been delayed to allow medication details to be finalised and to liaise with Miss X.
• No support plans were in place
• Accommodation 1 was in poor condition which was a direct consequence of poor planning.
• Contact arrangements and management of medication were not in place.
29. The adjudication reiterated the financial offer as offered at stage 2 of the process.
30. Miss X remained unhappy and complained to us.

The Council’s response to our enquiry letter

31. The Council reiterated is apology for the accepted faults outlined above. It said the circumstances were unique in that it happened at the start of the COVID-19 pandemic when care and social work staff were under significant pressure. It accepted the hospital’s focus had shifted from what was in F’s best interests to being about the availability of resources.
32. With regards to using unregulated care placements for 16 and 17 year olds such as F it said guidance and law had now changed. Guidance now places a responsibility on social workers to assess the quality and suitability of unregulated accommodation before placing someone there.
33. The Council referred us to the Ofsted inspection report of its Children’s services dated May 2022. Within this report it states ‘there is regular senior management scrutiny and oversight of those children and young people with complex needs who are placed in unregistered and unregulated settings’.
34. With regards to placement planning the Council said it now ensures senior management attends monthly NHS led multi-agency meetings to ensure early planning for young people takes place prior to discharge from mental health facilities.

My findings

35. It is not our role to reinvestigate matters which have already been subject to a properly conducted and independent investigation. To do so would not be a good use of public resources. Instead, our role is to consider the following.
• Was the investigation properly conducted and are the conclusions evidence based. If not, would the Ombudsman reach a different view based on the information available to us?
• Did the Council offer a proportionate remedy for the injustice caused by fault? If not, would the Ombudsman recommend any further remedial action?
• Has the Council fully implemented any agreed remedy? If not, has the delay caused any further injustice to the complainant?
36. The initial stage 2 investigation was found to be flawed after the IO failed to interview relevant people who were central to F’s discharge to Accommodation 1. There were also significant delays in completing the stage 2 investigation, exacerbated by the stage 3 panel directions for the addendum report.
37. Following the addendum report and the considerations of the stage 3 panel I am satisfied the investigation, albeit for the delays, was conducted properly. Miss X’s substantive complaints have been upheld and the investigation found the faults as outlined in paragraph 26. Therefore, it is left for me to consider whether the remedy offered is sufficient.
38. The circumstances around F’s discharge and the lack of placement planning caused both Miss X and F distress and upset. It leaves uncertainty around whether proper planning may have prevented F returning to the hospital. The Council has offered Miss X and F £250 each which is in line with our guidance and appropriate to recognise the injustice caused.
39. The Council has acknowledged the delays in completing stage 2 of the complaints procedure and has offered Miss X £200 to acknowledge the injustice caused to her. However, the Council took over two years to complete the stage 2 investigation. I have therefore made a recommendation for an increased payment, in line with our guidance to recognise the significant frustration and time and trouble caused to Miss X because of the delays.
40. This matter occurred over three years ago and the Council has explained how law and guidance has changed around unregulated placements. Ofsted has also carried out an inspection of the Council’s children’s services during that three year period. The Ofsted report highlights positive improvements in respect of the use of unregulated placements, management oversight and social worker engagement with parents. The Council has also taken steps to improve how it works with the NHS and other agencies with regards to placement planning of young people discharged from mental health facilities and hospitals. Given this, I have not made any further service improvement recommendations.

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Agreed action

41. Within one month of the final decision the Council agreed to:
1. Pay Miss X and F £250 each to acknowledge the distress and uncertainty caused by the faults identified following the statutory children’s complaints procedure.
2. Pay Miss X £500 to acknowledge the frustration and time and trouble caused by the significant delays in completing stage 2 of the statutory children’s complaints procedure.
42. The Council should provide us with evidence it has complied with the above actions.

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Final decision

43. I completed this investigation. I found fault and the Council agreed to my recommendations to remedy the injustice caused by the faults.

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Investigator's decision on behalf of the Ombudsman