Summary: Mrs F complained that the Council delayed assessing her daughter as a child in need, did not properly consider safeguarding concerns and failed to provide her with social care support. There was fault which caused uncertainty and distress to Mrs F and her daughter. The Council has agreed to make payments to remedy this and review its case note procedures.

The complaint

1. Mrs F complained on behalf of her daughter, J, that the Council delayed assessing her as a child in need, did not properly consider safeguarding concerns and has failed to provide her with the necessary social care support.
2. Mrs F says this has affected J’s behaviour, put her at risk and caused her to miss out on therapy. It has also had a significant impact on Mrs F’s mental and physical health and family relationships.

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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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. 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)

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How I considered this complaint

6. I spoke to Mrs F about the complaint and considered the information she sent, the Council’s response to my enquiries and the statutory guidance, Working Together to Safeguard Children.
7. Mrs F 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

Relevant law and guidance

8. The Children Act 1989 says councils have a duty to safeguard and promote the welfare of children within their area who are in need.

Safeguarding (section 47)

9. Councils must 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. (Children Act 1989, section 47)
10. If a local authority receives a report of concern about a child (a “safeguarding referral”), the council must decide within one working day whether:
• the child requires immediate protection, or
• the child is in need and should be assessed under section 17 of the Children Act 1989, or
• there is reasonable cause to suspect that the child is suffering, or likely to suffer, significant harm.
11. If the initial assessment suggests the child may be suffering, or be likely to suffer, significant harm, the council should hold a strategy discussion to enable it to decide, with other agencies including the police, whether to initiate safeguarding enquiries under section 47 of the Act.

Child in need (section 17)

12. At any stage when the council receives safeguarding concerns it may decide to offer services under section 17 of the Children Act 1989. Section 17 refers to services for ‘children in need’. A ‘child in need’ is one who “is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority”. This is because their “health or development is likely to be significantly impaired, or further impaired, without the provision […] of such services” or if they are disabled.
13. Where a council receives a referral suggesting a child may meet this definition it must carry out an assessment of need. This “child and family assessment” should be completed within 45 working days from the date of the referral. Following the assessment, if the council decides to provide services, a child in need plan should be developed.

Early help (Families First)

14. Councils may also offer “early help” services. These are forms of support aimed at improving outcomes for children or preventing escalating need or risk.
15. The Government’s statutory guidance says “Where a child and family would benefit from co-ordinated support from more than one organisation or agency (e.g. education, health, social care) there should be an inter-agency … early help assessment [to] … identify what help the child and family require to prevent needs escalating to a point where intervention would be needed through a statutory assessment under the Children Act 1989.” (Working Together, chapter 2 paragraphs 8 and 9)
16. The early help assessment can be undertaken by a lead practitioner such as a GP, family support worker, school nurse, teacher, health visitor and/or special educational needs co-ordinator.
17. The Council calls these assessments “Families First Assessments”. They may result in “Team Around the Family” meetings to agree an early help (or families first) plan.

Children’s statutory complaints procedure

18. 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 Independent Investigator 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 by an independent panel.
19. Regulations set out the timescales for the process. The Council should provide a response at stage one within 10 working days, at stage two within 25 working days (or exceptionally within 65 working days) and convene a review panel at stage three within 30 working days.
20. If a council has investigated something under this procedure, 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

21. Mrs F’s daughter, J, is autistic and has a health condition. She has been suicidal, with admissions to hospital, and was supported by child and adolescent mental health services (CAMHS). She has been known to the Council’s children’s social care services since 2016 and there have been safeguarding enquiries and missing persons assessments. She was supported by the Council’s SASH team, which provides support to teenagers where there is a risk of family breakdown or where young people go missing.
22. In January 2022, when J was 15 years old, Mrs F called the Council’s SASH team concerned about her behaviour. She said J was going missing after school, she was vulnerable and her behaviour was difficult to manage. She was visiting a boyfriend in a different town and was not receiving enough support at school. Mrs F felt at her wits end and unable to cope. A families first assessment was carried out and completed on 7 February. This determined J needed support from CAMHS and there was no role for SASH. J had been referred J to one of the Council’s support teams for young people, Step 2.
23. During the assessment in January a referral was received from the local NHS. It sent another referral on 14 March which said that J was in hospital as she had had suicidal thoughts. The Council spoke to Mrs F who said support was being provided by CAMHS.
24. In May, Mrs F called the Council a couple of times to say that J had gone missing. A missing person assessment was done. The NHS also emailed the Council. It said it had made a safeguarding referral on 6 May but had not had a response. The Council’s case notes do not show the 6 May referral, or whether there was a strategy discussion or a decision that a strategy discussion was not required.
25. Mrs F called the Council on 7 June with concerns about J going missing. I have seen no evidence of any action by the Council at this point.
26. Mrs F called again on 23 June as J had gone missing and the police were involved. The case record says a SASH worker would call Mrs F to discuss what support could be offered but I have seen no evidence that call was made.
27. Mrs F made a formal complaint on 4 July. She said that she had been contacting the Council persistently but they had only replied twice. Mrs F asked for support to manage J’s behaviour. I have set out how Mrs F’s complaint was dealt with in a separate section below.
28. A families first assessment was started on 12 July and completed on 27 July. It determined that a referral would be made to an NHS service which supports young people with autism. The Council also made referrals to mentorship schemes and to its youth support team.
29. During August, Mrs F called the Council four times with concerns about J, who had had a miscarriage. The social worker had left and I have seen no evidence the Council took any action until a new social worker was allocated on 22 August who agreed to visit.
30. On 6 September there was another referral from the NHS. The case notes do not show what action was taken in response. A further safeguarding referral was made on 8 September as J had contacted a helpline. I have not seen any evidence of a decision about whether a strategy discussion was needed.
31. On 16 September, a team around the family meeting noted that J had not engaged with the youth support team. CAMHS continued to support her. The meeting agreed J should be referred for a section 17 children and family assessment as there were concerns about her mental health.
32. The child and family assessment was started on 29 September. It should therefore have been completed by 24 November. It was not completed until 25 January 2023 as the social worker had to go off work unexpectedly in the autumn. The assessment was re-started on 1 December by a new social worker after J had been in hospital in November.
33. The assessment found J was a child in need and required a child in need plan due to being at risk of exploitation. The child in need plan said J needed support from CAMHS and the Council would work with her in relation to risk of exploitation.
34. The Council says it undertook intensive work around safety and exploitation with J, but she did not feel able to engage. There were a number of child in need meetings until the final one in September 2023 when the case was closed. The Council has referred J to its 0-25 Together service, which provides social care for disabled young people and young adults, for an adult social care assessment.

Mrs F’s complaint

35. The Council responded to Mrs F’s complaint on 2 August 2022. It said each time Mrs F contacted the Council, J’s case was closed as it was “felt appropriate given both mother’s ability to manage J’s behaviour, coupled with other support provided by CAMHS”. A new families first assessment had just been completed.
36. Mrs F remained dissatisfied and in September she emailed the Council saying there had been “catastrophic failures” in J’s support.
37. In October, the Council escalated her complaint to stage two of the children’s statutory complaints procedure. The Council appointed an independent investigating officer (IO) and an independent person to oversee the investigation. Mrs F agreed a statement of complaint on 6 December. The IO’s report should therefore have been issued by 10 March 2023.
38. The IO investigated the complaint, reviewed case records and interviewed relevant council officers. They issued their report on 20 March 2023. The IO upheld six of Mrs F’s seven complaints and partly upheld the seventh. In summary the complaints and findings were:
1. The stage one complaint response had not addressed all Mrs F’s concerns, for example addressing the risk of exploitation, poor communication and responses to safeguarding referrals.

Upheld.

2. Support strategies were not offered to J in a timely manner, and services to assist with her transition to adult services were not forthcoming or being considered.

Partly upheld – The Council had responded when Mrs F contacted them but “Each presenting episode seemed to be considered in isolation and the totality of the situation or cumulative effect appears not to have been managed.”

3. It was not evident how the service progressed the safeguarding referrals.

Upheld – section 47 procedures had not been followed and the case records were unclear about how referrals had been progressed.

4. A child and family assessment was only offered after Mrs F had complained.

Upheld – the assessment was started after Mrs F complained.

5. Mrs F was not advised until an education, health and care plan meeting in August 2022 that J had been referred for a child and family assessment.

Upheld – there was no evidence the Council had advised her before this.

6. There were delays progressing the child and family assessment.

Upheld – the social worker had had to go off work unexpectedly, so had been unable to advise Mrs F. In addition, there was then a delay in completing the assessment which was re-started in December.

7. The Council had failed to respond to Mrs F’s contacts.

Upheld.

8. The Council did not tell Mrs F that the social worker was off or what had happened to the child and family assessment carried out in autumn 2022.

Upheld.

39. The IO recommended the Council apologise to Mrs F, train staff on complaints responses, consider ways to inform people of the various assessment processes, review how work is managed when staff are absent, and ensure case notes were accurate.
40. The Council wrote to Mrs F on 6 April. It apologised for the delay in responding outside of the statutory 25 - 65 working day timescale. The Council accepted most of the IO’s findings but said there was no evidence that the child and family assessment had only been carried out because of Mrs F’s complaint. The Council accepted a lack of management oversight had led to a lack of continuity and deficiency in service for J and to Mrs F. It had an action plan to address the IO’s recommendations. It apologised and offered Mrs F a goodwill gesture payment of £300 for the distress the delays may have caused.
41. Mrs F remained dissatisfied and asked for her complaint to be escalated to stage three. The stage three panel was held on 26 June. It upheld all Mrs F’s complaints and recommended Mrs F meet with the Council to enable the Council to learn from her experiences.
42. The Council wrote to Mrs F on 18 July accepting the findings and recommendations made by the panel. It said the impact on Mrs F’s and J’s life could not be assessed through the complaint process and suggested Mrs F contact the Council’s insurers. The Council met Mrs F on 21 August. Mrs F came to the Ombudsman.

My findings

43. Following the IO’s investigation, the Council has accepted there was:
• a two-month delay in carrying out a child and family assessment,
• a failure to record or respond to safeguarding referrals in 2022, and
• poor communication with Mrs F in 2022.
44. That is fault and I will consider below how it affected J and Mrs F.
45. The crux of Mrs F’s complaint was that the Council had failed to offer sufficient support to J. She also says the Council does not have services appropriate for a person with autism.
46. It is for the Council, not the Ombudsman, to determine what support J needs and to refer to services they consider appropriate. My role is to consider if the Council has followed the correct process for establishing a person's needs and if it acted correctly when this process was complete. I have therefore reviewed whether the decisions to not escalate J’s case to a child and family assessment prior to September 2022 were made without fault.
47. When Mrs F contacted the Council in January 2022, a families first assessment was done and completed on 7 February. This found there was no role for SASH and that J should be supported by CAMHS. Referrals were made to other services, but I understand J does not engage with these.
48. Another families first assessment was done in July 2022, starting after Mrs F complained. This again found there was no role for SASH; CAMHS would make a referral to an NHS autism service and a referral was made to the youth support team.
49. I have seen no evidence of fault in the way the assessments were done and I therefore cannot criticise the decision not to refer J for a child and family assessment in January 2022 or July 2022, or which services to refer her to. I realise Mrs F disagrees but I cannot challenge the outcome of an assessment if there has been no fault in the way it was done.
50. I have seen no record of a decision to refer J for a child and family assessment prior to the 16 September 2022 team around the family meeting, so on the evidence seen I cannot say that Mrs F should have been advised of this before August 2022.
51. Other than the delay, there is no evidence of fault in the way the child and family assessment was done and the child in need plan drawn up. So I cannot challenge its findings that J required mental health support and some support around risks of exploitation.

Did the fault cause injustice?

52. I am satisfied that the apology already provided by the Council is a proportionate and appropriate remedy in line with our guidance for the time and trouble caused by the delays in the complaint process.
53. The Council has already taken action to implement the recommendations made by the IO and met with Mrs F as recommended by the panel. However, I consider the Council has failed to remedy the injustice caused by:
• Delay in issuing a child in need plan. If there had been no delay, J would have had a child in need plan by the end of November 2022. Whilst the provision in the plan is similar to that in the earlier families first plans, my view is this caused some distress to J as she will never know if an earlier plan could have helped her.
• Failure to respond to Mrs F in 2022. The case records show Mrs F called the Council about six times in summer 2022 but was not always responded to. Whilst there is no duty on the Council to continually repeat an assessment, given J’s needs and vulnerabilities I find this caused distress to Mrs F who was struggling to cope.
• Not recording the outcomes of NHS safeguarding referrals. Mrs F was aware that the NHS had been making referrals to the Council when J was in crisis. But there is no record of how these referrals were dealt with. This causes uncertainty about whether there should have been strategy discussions or safeguarding enquiries. I consider this adds to the distress to Mrs F as she was concerned that nothing was being done after referrals had been made.
54. When we have evidence of fault causing injustice we will seek a remedy for that injustice which aims to put the complainant back in the position they would have been in if nothing had gone wrong. When this is not possible, we will normally consider asking for a symbolic payment to acknowledge the avoidable distress caused. But our remedies are not intended to be punitive and we do not award compensation in the way that a court might. Nor do we calculate a financial remedy based on what the cost of the service would have been to the provider. This is because it is not possible to now provide the services missed out on. Our remedies guidance says a moderate, symbolic payment is appropriate to remedy distress and uncertainty caused by fault.

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Agreed action

55. Within a month of my final decision, the Council has agreed to:
• Pay Mrs F £300 to remedy the distress and uncertainty caused by the fault outlined above.
• Pay J £200 to remedy the uncertainty caused by the delay in completing the child and family assessment.
• Review its case note procedures to ensure there are clear records of decision-making following safeguarding referrals.
56. The Council should provide us with evidence it has complied with the above actions.

Final decision

57. There was fault by the Council. The actions the Council has agreed to take remedy the injustice caused. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman