Summary: The Council was at fault for considering Mr X’s complaint through the wrong process (the children’s statutory complaints procedure). It then failed to properly consider the complaint at stage two and stage three of the children’s statutory complaints procedure in line with the relevant law and statutory guidance. The Council has agreed to apologise to Mr X, pay him a financial remedy and reconsider his complaint. It has also agreed to create an action plan to prevent similar fault occurring in the future.

The complaint

1. Mr X complained about the Council’s investigation into his concerns which were predominantly about the handling of a section 47 investigation, initial child protection conference (ICPC) and a subsequent child protection plan.
2. The Council investigated Mr X’s complaint under the statutory children’s complaints procedure. However, he was unhappy with the outcome as he said it had failed to consider his complaint in line with relevant law and guidance.
3. Mr X said this caused distress, frustration and uncertainty.

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The Ombudsman’s role and powers

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 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)
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(1), as amended)
6. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).

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How I considered this complaint

7. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance.
8. Mr X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

Children’s statutory complaints procedure

9. 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. We also published practitioner guidance on the procedures, setting out our expectations.
10. When deciding if a complaint should be considered under the procedure councils should check which part of the Act the service being complained about falls under. Generally, Child protection including S47 enquiries and conferences is exempt.
11. Generally, assessments and services in the following areas should be considered under the procedure:
• Children in need
• Looked after children
• Special Guardianship support
• Post-adoption support
• Early help (if it was delivered under section 17 of the Children Act 1989)
12. The first stage of the procedure is local resolution. Councils have up to 20 working days to respond.
13. If a complainant is not happy with a council’s stage one response, they can ask that it is considered at stage two. At this stage of the procedure, councils appoint an investigating officer (IO) to look into the complaint and an independent person (IP) who is responsible for overseeing the investigation and ensuring its independence.
14. Following the investigation, a senior manager (the adjudicating officer) at the council should carry out an adjudication. The officer considers the IO report and any report from the IP. They decide what the council’s response to the complaint will be, including what action it will take. The adjudicating officer should then write to the complainant with a copy of the investigation report, any report from the independent person and the adjudication response.
15. The whole stage two process should be completed within 25 working days but guidance allows an extension for up to 65 working days where required.
16. 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. The council must hold the panel within 30 working days of the date of request, and then issue a final response within 20 working days of the panel hearing.
17. The stage three review panel should not reinvestigate complaints nor should it be able to consider any substantively new complaints that have not been first considered at stage two. The Chair should ensure that the Panel’s focus is on the agreed complaint and the complainant’s desired outcomes from the Stage two investigation.
18. The Panel is required to produce a written report containing a brief summary of the representations and their recommendations for resolution of the issues. They must send this to the complainant, the local authority, the independent person from Stage 2 and any other person with sufficient interest within 5 working days of the Panel meeting. The written record should set out simply and clearly a brief summary of the representations; their recommendations for the resolution of the issues and the reasons for them. If a Panellist disagrees with the majority recommendation, this should also be recorded and the reason for it given.

London Safeguarding Children’s Procedures

19. The London Safeguarding Children Procedures set out multi-agency arrangements for protecting children at risk of harm across London. Complaints under these procedures generally relate to concerns about the way safeguarding professionals or agencies have handled child protection cases, including how inter-agency processes were followed or whether safeguarding duties were fulfilled. Such complaints are typically managed at the agency level, often using the individual organisation’s own complaints processes, but they may also be escalated to the safeguarding partnership for review of multi-agency practice.
20. The complaints London Safeguarding Children procedure also has three stages:
• Stage One: Informal Stage. This involves the manager responsible for the ICPC service and the ICPC Chair.
• Stage Two: Formal Stage – Complaint Meeting. This involves the manager responsible for the ICPC service and/or Senior Manager for Children Safeguarding.
• Stage Three: The Appeal Panel. The Chair of the Panel will be a senior manager from the Safeguarding Children Partner agencies. The Panel will be an interagency panel made up of at least two senior representatives from Safeguarding Children Partnership agencies, none of whom have previous or present direct line management responsibility for the case in question.
21. Parents have the right to make complaints in respect of one or more of the following aspects of the functioning of child protection conferences:
• The process of the conference.
• The outcome, in terms of the fact of and/or the category of primary concern at the time the child became the subject of a child protection plan.
• A decision for the child to become, to continue or not to become, the subject of a child protection plan.
22. The potential decisions of the stage three panel are as follows:
• That Child Protection Conference procedures were followed correctly;
• That Child Protection Conference procedures were not followed correctly and recommend how to remedy this;
• To support the original Child Protection Conference decision;
• Recommend the Child Protection Conference is reconvened with the same or different conference chair, to reconsider a recommendation regarding the decision that the child should be or continue to be, subject to a Child Protection Plan and the category of Significant Harm on which such decision is based;
• To decide they have insufficient information to make a decision and set out a timescale for completing the task and set a date for a further panel; and
• To decide whether there are any learning points for a specific agency.

Child Protection Conference arrangements

23. If, following a referral and an assessment by a social worker, a multi-agency strategy meeting decides the concerns are substantiated and the child is likely to suffer significant harm, the council convenes a Child Protection Conference.
24. The Child Protection Conference decides what action is needed to safeguard the child. This may include a recommendation that the child should be supported by a Child Protection Plan.
25. After the Initial Child Protection Conference, there will be one or more Review Child Protection Conferences to consider progress on action taken to safeguard the child and whether the Child Protection Plan should be maintained, amended, or discontinued.
26. The Child Protection Conference is a multi-agency body and is not in itself a body in the Ombudsman's jurisdiction.

EHC Plans

27. A child or young person with special educational needs may have an Education, Health and Care (EHC) Plan. This document sets out the child’s needs and what arrangements should be made to meet them. The EHC Plan is set out in sections. We cannot direct changes to the sections about their needs, education, or the name of the educational placement. Only the Tribunal or the council can do this. 

Background

28. Mr X is a single parent to his child, Y. In October 2023, the Council became involved due to concerns Y would be permanently excluded from school due to their aggressive behaviour.
29. The school also made a referral to the Council about Mr X’s parenting. As a result of the referral, the Council commenced a section 47 enquiry, held an initial child protection conference (ICPC) and decided Y should be subject to a child protection plan under the category of neglect.

What happened

Stage one

30. Mr X made a complaint a stage one complaint in March 2024 about the Council’s handling of the child protection proceedings. The Council issued a stage one complaint in April 2024 not upholding the concerns. Mr X requested this was escalated to stage two the same month. The Council did not carry out the stage two until May 2025 due to court proceedings relating to the concerns.

Stage two

31. The investigating officer (IO) started the investigation by saying The Children Act 1989 requires every local authority to establish a procedure for considering complaints about some of its statutory functions, made by or on behalf of any child ‘looked after’ or in need.
32. The IO identified 6 points of complaint as follows:
1. There have been various issues raised by Mr X regarding school reports and their actions.
2. The Initial Child Protection Conference (ICPC) did not represent Mr X’s views and contained incorrect information taken from school reports.
3. Mr X was not fully prepared for or informed of the ICPC. The Council did not provide him with a copy of the report for the ICPC.
4. The social workers carried out unannounced visits to Mr X’s home and social workers said they would have to go to court.
5. The social worker did not listen to Mr X whilst in conversation and Mr X did not feel heard.
6. There was a delay with the paediatric assessment of Y.
33. The statement of complaint goes into further detail about each of the six points:
1. In relation to complaint one, Mr X said the Council was unduly influenced by the school’s concerns about Mr X and his child, without talking to Mr X or investigating the circumstances. Mr X had approached the Council for support months prior and it refused to help. He also said the Council failed to consider whether Y’s behaviour was a result of their neurodiversity.
2. In relation to complaint two, Mr X said the chair of the ICPC asked him the colour of his skin which was inappropriate. He also said Y was on child protection under the category of neglect. This came from information the school had provided but Mr X said the Council refused to ask the school about the allegations.
3. In relation to complaint three, no further detail was required.
4. In relation to complaint four, Mr X said social workers should not have carried out visits as the Council should not have put Y on a child protection plan in the first instance.
5. In relation to complaint five, Mr X said the Council did not listen to Mr X’s concerns about Y’s neurodivergence. Mr X said the Council initiated child protection proceedings without considering how his neurodiversity was impacting on his behaviour.
6. In relation to complaint six, the paediatric assessment was allegedly delayed due to Mr X not signing a form. However, Mr X said he had a letter from the head teacher of Y’s school confirming he signed it.
34. The stage two report shows the IO did not uphold any of the complaints for the following reasons:
1. In relation to complaint one, the IO did not uphold the complaint because they said it was more of a statement than a complaint. The IO said it has viewed Y’s EHC Plan which is a comprehensive document detailing his special educational needs. They also said the Council had a duty to follow up on any concerns raised by the school about the well-being of a child.
2. In relation to complaint two, the IO did not uphold the complaint because it said there is a record to show Mr X was asked for his views. They also there was no evidence the ICPC chair asked Mr X the colour of his skin.
3. In relation to complaint three, the IO did not uphold the complaint because there was evidence he received a copy of the report for the ICPC and then contacted the Council to discuss this.
4. In relation to complaint four, the IO did not uphold the complaint because social workers have to carry out visits as part of the statutory child protection process. They also said there was no evidence that social workers had ever used court proceedings as a threat.
5. In relation to complaint five, the IO did not uphold the complaint because Y did not have a formal diagnosis and this was being explored via the EHC Plan route. The IO said it was unable to comment on Mr X’s view that staff were not listening to him.
6. In relation to complaint six, the IO did not uphold the complaint. There was a delay with paediatric assessment as the school delayed sending the referral form. The IO said Mr X needed to pursue the matter with the school.
35. The independent person (IP) agreed with the IO’s findings and confirmed the IO conducted the investigation in a fair and unbiased way.
36. The adjudicating officer (AO) wrote to Mr X to notify him of the findings at the end of May 2025.

Stage three

37. At the end of June 2025, Mr X requested the complaint was considered at stage three. His grounds for escalation were as follows:
• The school had since confirmed its referral to social care was factually inaccurate. The Council failed to check the accuracy of the referral prior to social work intervention.
• The Council withdrew its application for care proceedings after 10 months of care action.
• There was racial discrimination at the ICPC.
• Mr X did not receive the report in advance of the ICPC.
• The Council’s entire involvement was triggered by the school’s unsubstantiated referral. At no point were Mr X’s views considered objectively or given equal weight.
• The prolonged and unjust intervention had a severe impact on both Mr X and Y.
38. The Council held the stage three panel meeting in August 2025. The panel focussed both on Mr X’s grounds for escalation and the stage two report. The panel made the following findings:
• In relation to complaint one, the panel said it did not have sufficient information to reach a definitive finding. This was because complaint one did not sufficiently encompass the range of concerns Mr X had raised in his statement of complaint. For example, that children’s services refused to help Mr X when he approached them three months prior to the school making the referral.
• In relation to complaint two, the panel said it was unable to reach a definitive finding as the IO did not investigate a key element central to the complaint about Y being subject to child protection under the category of neglect.
• In relation to complaint three, the panel concluded this should remain as not upheld.
• In relation to complaint four, the panel said it was unable to reach a definitive finding. This was because in Mr X’s statement of complaint he raised issue with the decision to place Y on a child protection plan. However, the IO only investigated social work visits and the threats of court proceedings.
• In relation to complaint five, the panel said it was unable to reach a definitive finding. This was because it did not address Mr X’s claim that the child protection route was instigated without exploring the child’s behavioural needs.
• In relation to complaint six, the panel concluded this should remain as not upheld.
39. The panel also commented that since Mr X’s primary concern relates to the decision to place the child under a child protection plan, the Council should have given him the opportunity to pursue this via the London Safeguarding Children complaints procedures. Had this occurred, the stage three panel could have reached a conclusion about whether the Child Protection Conference procedures were followed correctly.
40. The stage three panel made six recommendations:
1. Arrange for Mr X’s complaint to be considered by the stage three appeal panel in line with the London Child Safeguarding Procedures.
2. Apologise and provide financial compensation for procedural faults in the complaint handling process.
3. Review its complaint handling process including providing training to staff to ensure it considers complaints properly.
4. When triaging complaints, the Council should provide rationale for which complaints procedure it uses.
5. Ensure formal notes are taken at panel meetings as when the chairperson contacted the Council to request a copy of the notes in this case, there were none.
41. The stage three adjudication letter set out the following:
• At the Stage 3 panel hearing, the panel focused on Mr X’s grounds for escalation instead of going through each of the complaints that had not been upheld in the Stage 2 investigation in the usual way. As a result, it could only comment on the grounds for escalation;
• The panel did not reach a unanimous decision; two Panel Wing Members have written separately to confirm their disagreement with the report; and
• It went through each ground for escalation and concluded it did not uphold any of them.
42. The Council’s response to the panel recommendations were as follows:
• In response to recommendation one, the Council said it was unable to accept the complaint be reconsidered by a stage three panel through the London Child Safeguarding Procedures as the statutory framework does not permit the panel to adjudicate on the substance of child protection decisions.
• In response to recommendation two, the Council said it did not accept any failing occurred and there is no basis for issuing either an apology or financial remedy.
• In response to recommendation three, the Council said it did not consider a review of the existing processes necessary. It said it did not accept that there were procedural shortcomings and the concerns were properly considered under stage two.
• In response to recommendation four, the Council said the statutory complaints procedure was correctly applied and therefore, does not accept this recommendation.
• In response to recommendation five, the Council said it accepted this recommendation. However, traditionally panel members take their own notes, and it is the responsibility of the panel chair to indicate in advance if formal minutes are required.
43. Mr X remained dissatisfied with the Council’s handling of the matter and complained to us.

My findings

44. Mr X complained about the Council’s action in relation to a child protection investigation and plan for his child Y. The Council considered the complaint through the children’s statutory complaint procedure.
45. We are not an appeal body. We cannot question the Council’s decision because someone disagrees with it. We can only decide if there was fault in the way the decision was reached.

Stage two investigation

46. The IO sets out in the stage two report that the Children Act 1989 requires every local authority to establish a procedure for considering complaints about some of its statutory functions, made by or on behalf of any child ‘looked after’ or in need. However, Y was not a ‘looked after’ child or a child in need. This complaint directly relates to a section 47 investigation and subsequent child protection plan so it was exempt from the statutory complaints process.
47. The Council can choose to put it through the statutory complaints procedure but it should be able to provide a rationale for doing so. Putting it through this process with no rationale for doing so was fault and this has significantly delayed Mr X receiving a meaningful outcome. As the Council has considered the matter through the statutory complaints procedure, we would not usually expect for the complainant to go through another process if it has properly considered the complaint. However, the findings at stage two and stage three were flawed and the reasons for this are set out below.
48. The IO did not uphold complaint one as they said it was more of a statement than a complaint. However, it was the Council who drafted it in that way within the stage one complaint response. It is clear from the statement of complaint Mr X was complaining that the Council was influenced by the school and failed to verify the concerns with Mr X. The IO decided the Council was not unduly influenced by the school and so, the IO should not have upheld the complaint for this reason. The IO did not do this, so the Council was at fault.
49. Mr X also complained the Council failed to provide Mr X with support when he approached the Council three months prior. The IO did not investigate this despite it being in the statement of complaint. Therefore, the Council was at fault for failing to investigate the full complaint.
50. In complaint points two, four and five, Mr X raised concern the Council used the primary category of neglect and the ICPC outcome which was to place Y on a child protection plan. Mr X also raised the Council had not considered Y’s neurodiversity during proceedings. The most appropriate procedure to look at this is the London safeguarding children procedures. The Council was at fault for failing use this procedure to investigate this aspect of Mr X’s complaint. It was also at fault for failing to explain the reasons for not investigating it in its stage two report.
51. For the reasons set out above the stage 2 investigation cannot be relied on. Mr X has raised concerns with the outcome of the ICPC, the use of the primary category of neglect, the conduct of the chair of the ICPC and the reliability of the section 47 investigation. Had the Council used the London safeguarding children procedures, it could have investigated these elements of the complaint. Had there been fault with how it carried out the child protection proceedings, it could have reconvened the child protection conference to reconsider the decision to place Y on a child protection plan under the category of neglect.

Stage three investigation

52. The stage three Panel’s purpose is to consider the adequacy of the stage two investigation. Following the panel completing the stage three report, two of the panel members wrote to the Council to state their disagreement with the report. However, the statutory guidance states that if a panellist disagrees with the majority recommendation, this should be recorded and the reason for it given in the report. The panel has not followed the correct process as there is no record of disagreement in the report. Therefore, the Council was at fault and its stage three outcome cannot be relied on.
53. The AO’s stage three letter said it could only comment on the grounds for escalation as the panel only focussed on this. However, the stage three panel went through each point of complaint and made a finding so the AO should have commented on this in the letter. The AO did not do this and therefore the Council was at fault.
54. The AO’s stage three letter said it did not uphold any of the grounds of escalation and it did not accept that there were procedural shortcomings. It said the concerns were properly considered under stage two. It is the role of the AO to include its response to the panel’s recommendations. However, the regulations do not permit the Council to disagree with the panel’s findings. Therefore, the Council was at fault.
55. The faults identified in both the stage two and stage three of the statutory complaint’s procedure have caused Mr X distress, frustration and uncertainty about the outcome.

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Action

56. Within one month of the final decision, the Council has agreed to:
1. Apologise to Mr X for the injustice caused by the faults identified at stage two and stage three of the statutory complaints procedure. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council should consider this guidance in making the apology I have recommended.
2. Pay Mr X £500 for the injustice caused by the faults identified at stage two and stage three of the statutory complaints procedure.
3. Identify the complaints relating to child protection matters and arrange for these to be considered at stage two through the London Safeguarding Children procedure. The stage two should take no longer than 28 days. It is for Mr X to decide whether to escalate this to stage three if he remains dissatisfied.
4. Arrange a phone call with Mr X to discuss whether he would like to pursue the remaining complaints. If he does, the Council should consider these through its corporate complaints procedure.
57. Within three months of the final decision, the Council has agreed to:
1. Review this case to identify why these faults occurred at stage two and stage three and create an action plan to prevent this from occurring in the future.
58. The Council should provide us with evidence it has complied with the above actions.

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Decision

59. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman