Summary: Ms G complains health and children’s services in her area failed to appropriately monitor and support her child during his early years. We will not investigate the complaint because it is late and we have not found a good reason to use discretion to investigate it now. And, because Ms G is seeking sizeable financial compensation for avoidable harm, it would be appropriate for her to pursue a remedy through the courts.

The complaint

1. Ms G complains:

• About a failure to start close developmental monitoring of her son, T, after his birth in December 2013.
• About a failure to respond appropriately to the outcome of a Schedule of Growing Skills (SOGS) assessment of T in April 2018. This includes a complaint that a health visitor failed to complete a suitable, adequate assessment after this time.
• A health visitor recorded inaccurate information in T’s records (specifically, that T was not attending nursing) which, in turn, fed into a failure to work collaboratively with other services in a coordinated way.
• Health visitors later failed to acknowledge the concerns raised by T’s nursery.

2. Suffolk County Council (the Council) is responsible for the health visiting service in Ms G’s area. East Suffolk & North Essex NHS Foundation Trust (ESNEFT) is responsible for the hospital where T was born. NHS Suffolk & North East Essex Integrated Care Board (the ICB) commissions health services in Ms G’s area. And Norfolk & Suffolk NHS Foundation Trust (NSFT) is responsible for relevant children’s assessment services.
3. Ms G said failings throughout this time meant T missed out on: enhanced developmental tracking; follow up assessments; timely referrals to helpful services; and, an opportunity to benefit from inter-agency feedback and coordinated support. Ultimately, Ms G said T missed out on NHS-led support and interventions for a prolonged period. Ms G said that, at the time of complaining to the Ombudsmen, T was 11 and “out of education, years behind developmentally, emotionally distressed, and requires specialist provision”. Ms G said this could have been avoided had the fault not occurred.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
5. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
6. The law says we cannot normally investigate a complaint when someone could take the matter to court. However, we may decide to investigate if we consider it would be unreasonable to expect the person to go to court. (Local Government Act 1974, section 26(6)(c), as amended and Health Service Commissioners Act 1993, section 4(1b))
7. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we would find fault, or
• we cannot achieve the outcome someone wants, or
• there is another body better placed to consider this complaint.

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

8. I considered the written information Ms G provided to the Ombudsmen. I considered papers the Council and the ICB provided to us.
9. I considered LGSCO’s Assessment Code and PHSO’s guidance on deciding whether to investigate.
10. I shared a confidential draft copy of my provisional decision with Ms G and invited her comments on it.

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What I found

11. T was born prematurely in December 2013. He was cared for in a Neonatal Intensive Care Unit for seven days. T began attending a nursery when he was one. Ms G said when T was four:

• His nursery made a referral which noted concerns about his development, and
• a SOGS assessment showed T had delays of over 13 months in multiple areas of development.

12. Ms G said, following the SOGS assessment, a health visitor documented that the assessment had not raised any concerns. Ms G said, later, a health visitor observed T in his nursery and concluded there were no significant concerns.
13. In July 2024 Ms G contacted the ICB and said a request for an assessment of T had been made some time ago. Ms G said that in the intervening period she had seen a dramatic change in T and he was now at risk of being excluded from school. Ms G said T’s school had identified him as having social, emotional and mental health difficulties. Ms G said the Education Health and Care Plan (EHCP) process had begun. The ICB replied and said responsibility for assessing T had been passed to NSFT.
14. Ms G complained to ESNEFT in July 2025. Her concerns were then passed on to the ICB and to the Council.
15. In October 2025 the ICB wrote to Ms G. The ICB said ESNEFT had not been able to investigate her concerns “as they are outside of their timescales to respond”. The Council wrote to Ms G in November 2025 and said “these matters fell outside the scope of its complaints process “which operates a one-year consideration timescale”.
16. In her complaint to the Ombudsmen Ms G said after T’s birth, she had limited support and trusted professionals to do the right thing. Ms G said her complaint stemmed from having obtained and read T’s full medical records.
17. However, Ms G also said she was “consistently dismissed, misled, and blamed. At every stage, professionals deferred responsibility back to me and to educational settings.” This would suggest that Ms G did have some concerns about a lack of support and a lack of appropriate referrals and interventions during T’s early years. As such, while Ms G’s eventual request for, and access to, T records provided more detail, on balance it seems more likely than not that Ms G had some knowledge of her concerns by 2018 when a SOGS assessment noted concerns about T’s development. And, by July 2024, Ms G knew of her concerns about significant issues with T’s development. And Ms G knew at that time that a request for an assessment had been made but not been acted on.
18. Therefore, Ms G’s complaint to the Ombudsmen, in December 2025, was made more than 12 months after her knowledge of her concerns. Complaints should be brought to the Ombudsmen within 12 months of the person becoming aware of their concerns. As such, the complaint is late.
19. Given the significance of these concerns it would have been appropriate to have made complaints to relevant services as soon as possible. From the evidence currently available, I have not seen anything to suggest there was anything which prevented Ms G from doing this. Further, the complaints systems is designed so people do not need to have access to all evidence, such as medical records, before making a complaint.
20. A considerable amount of time has now passed since the events complained about. Given the extended passage of time and number of variables involved, it is highly improbable that an investigation would be able to make meaningful, evidence‑based findings about the impact of any potential failings. For example, if an investigation found T should have had additional monitoring, or should have been referred to a specific service, we would not be able to say what the outcome of any monitoring would have been, or what would have happened with a referral. Equally, we would not be able to do anything other than speculate on how effective any given service would or would not have been.
21. Overall, there is no compelling reason for the Ombudsmen to exercise discretion to look at Ms G’s complaint even though it is late.
22. Ms G has also said she plans to take legal action to seek redress for the impact of the claimed failings on T. In bringing her complaint to the Ombudsmen Ms G said she would like T to receive financial compensation for the impact these events have had and will continue to have on him. Ms G specified that, in relation to PHSO’s severity of injustice scale, she considers a level six payment would be appropriate. Level six payments are for £12,500 or more, for cases “involving profound, devastating or irreversible impacts on the person affected”. In view of this desired outcome, it seems it would be (or would have been) reasonable for Ms G to seek a resolution to her complaint via the courts. And, as such, this is another reason why the Ombudsmen cannot investigate her complaint.

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Decision

23. We have closed this case on the basis that the Ombudsmen cannot investigate the complaint because it has been made late and there is no reason to set the time limit aside. And because it would be appropriate for Ms G to pursue an alternative legal remedy.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman