Summary: Ms X complained about the Council’s handling of her daughter, Y’s social care case. The Council was at fault for poor record keeping, failing to keep Ms X properly updated, not taking the action set out in a child in need plan, not properly considering whether Y was safe in her father’s care, not holding a split meeting in September 2022, a delay in transferring the case to another council and poor complaints handling. It should apologise for the distress and uncertainty caused, pay Ms X £750, and make service improvements.

The complaint

1. Ms X complained about the Council’s handling of her daughter, Y’s, child in need plan. In particular, she said the Council:
1. did not properly consider the risks posed to Y by her father, Mr Z, and did not take appropriate action to ensure her safety;
2. did not carry out the actions set out in Y’s child in need plan;
3. did not share information appropriately with Ms X, including about concerns of a physical assault and Y’s visit to A&E on 10 June 2022;
4. did not keep accurate records, including recording meetings with Ms X that did not take place;
5. expected Ms X to attend a professional meeting in September 2022 which Mr Z was also attending, despite the Council being aware she was a victim of domestic abuse involving Mr Z, and not warning her in advance that he would be attending;
6. recorded in the child in need plan that Ms X had mental health difficulties and needed a mental health assessment, but there was no basis for this;
7. delayed transferring the case to Council B after Y moved back to her care in September 2022; and
8. failed to properly investigate and respond to her complaint.
2. Ms X said the failings caused considerable distress as she considered Y was not protected or supported between April and December 2022. And she was frustrated because she felt she was not listened to. She was also put to avoidable time and trouble pursuing the complaint, including having to make a subject access request to obtain the records so she could challenge the inaccurate accounts given in complaint responses. She said Y, who suffers from social anxiety, became withdrawn as she was left alone for much of the time, was not receiving support and was not attending school.

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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. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
6. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).
7. 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

8. I considered:
• the information Ms X provided and spoke to her about her complaint;
• the information the Council provided in response to our enquiries;
• relevant law and guidance, as set out below; and
• our guidance on remedies, as set out on our website.
9. Ms X and the Council had an opportunity to comment on my draft decision and I considered their comments before making a final decision.

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What I found

Relevant law and guidance

10. Councils have a 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. (Children Act 1989, section 47)
11. The council should make initial enquiries of agencies involved with the child and family, for example, health visitor, GP, schools and nurseries. The information gathering at this stage enables the council to assess the nature and level of any harm the child may be facing. As a result of these enquiries, the professionals may decide the child needs to be supported through a child protection plan.

Child in need

12. Section 17 of the Children Act 1989 says councils must safeguard and promote the welfare of children within their area who are in need.
13. 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. When a council assesses a child as being in need, it supports them through a child in need plan. This should set clear, measurable outcomes for the child and expectations for their parent. Councils should review child in need plans regularly.

Children and Adolescent Mental Health Service (CAMHS)

15. CAMHS is a health service for children, and their families, who need support for mental health issues. CAMHS also carry out assessments for conditions such as autism and attention deficit hyperactivity disorder (ADHD).

The Council’s corporate complaints process

16. The Council operates a two stage complaints process. Its corporate complaints process says:
• at stage 1, a service manager will respond within 15 working days:
• at stage 2, the complaint will be reviewed by a senior manager, and a ful written reply sent within 20 working days.

Children’s statutory complaints process

17. 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. Complaints about child protection are excluded from this process.
18. The process involves:
• at stage 1, a written response within 20 working days;
• at stage 2, an investigator is appointed to investigate the complaint, overseen by an independent person, and a report should be issued within 13 weeks;
• at stage 3, an independent panel, which issues a final response within 20 days of the panel meeting.

Practitioner Guidance

19. We published guidance for practitioners on the children’s statutory complaints process in February 2022. This replaced earlier guidance published in 2015, which identified the same common issues. This says where a council receives a complaint which partly falls within the children’s statutory complaints process and is partly outside it, councils should consider investigating all parts of the complaint under the statutory process and issuing a single complaint response. The guidance also says (page 11) councils should keep a detailed records, including any decision not to use the statutory complaints process.

This Council’s complaints process

20. The Council’s policy says it will acknowledge complaints at stage 1 within three days and provide a written response within 15 working days. It says its aim is to resolve as many complaints as possible at this stage. This means “responses must be open and honest, admitting fault when things have gone wrong and setting out a package of measures to put things right”.
21. If the customer remains unhappy they can ask for the complaint to be reviewed at stage 2 by a more senior manager. At stage 2 a full written response will be sent within 20 working days.

What happened

22. Ms X lives in Council B’s area. She was separated from Y’s father, Mr Z, following domestic abuse. In February 2022, Y went to live with her father in this Council’s area. Ms X said that from this point, Y did not have contact with her for seven months and her number was blocked on Y’s mobile phone.
23. In April 2022, Council B made a referral to this Council. It said Y had been supported by a child in need plan from since October 2021. It said it had concerns about Y’s mental health, her lack of engagement with professionals, poor school attendance and the impact of parental conflict.
24. Also in April 2022, a charity made a referral. The charity said Ms X had reported that Mr Z was not taking Y to CAMHS appointments and was not encouraging her to attend school, so her attendance was poor. Ms X said Mr Z was turning Y against her.
25. The Council allocated a social worker, officer 1, to make enquiries. Council records refer to a home visit on 5 May 2022, but Y refused to speak to officer 1. A full record of the visit was not made.
26. Council records also state officer 1 met with Ms X on 27 May 2022. The record says Ms X disclosed Mr Z had emotionally abused her and she had suffered emotional abuse. She said she was worried Mr Z:
• was manipulating Y by speaking badly about her;
• would emotionally abuse Y;
• had stopped Y engaging with professionals, such as CAMHS.
27. Council records refer to a virtual child in need (CIN) meeting with Y’s school on 10 June 2022 to discuss “the situation with [Y] particularly her attendance and emotional presentation. The father sent his apologies as he was unable to attend. At the time it was felt that threshold was met for ICPC [an Initial Child Protection Conference]. Both parents were updated accordingly”. There is no record Ms X was invited to this meeting, although she was told an ICPC was being arranged. The Council was not able to provide a record of the June meeting.
28. Ms X said Y was self-harming whilst in her father’s care, and on 10 June Y’s school asked Mr Z to take Y to hospital, which he did. There is no record of the hospital visit in the Council’s records I have seen. Ms X said the school told her about the hospital visit two weeks later. In its initial complaint response, the Council said it understood Y was in touch with Ms X by mobile phone. In a later response, it said the social worker spoke to Ms X about the hospital visit a few days later, but accepted there was no record of that contact. In its final complaint response, it apologised for not telling her earlier.
29. Ms X said when Y was discharged from the hospital, Mr Z agreed she should not be left on her own. However, Ms X said Y was often left alone whilst Mr Z was working, and said she raised concerns about this on a number of occasions. In its complaint response, the Council referred to Y’s paternal grandmother helping with her care, but Ms X said the paternal grandmother does not live in the U.K and was only in the country for three weeks from late May and for two weeks from late August 2022.
30. The Council arranged a strategy meeting, which took place on 14 June 2022. At that stage, the records stated the threshold for child protection had been met. Officer 1 was asked to make enquiries and arrange an ICPC.
31. In her complaint to the Council, Ms X said she raised concerns about Y’s safety on 28 June 2022 because no-one had seen Y for 18 days. There is no record of this contact in the records I have seen. The Council’s initial complaint response said officer 1 had a video call with Mr Z and Y, because Y was more comfortable with this. There is no record of this contact and Mrs X said she was not updated.
32. Also in her complaint, Ms X referred to Y travelling to visit her in July 2022 and getting lost. I have not seen a record for this incident. In its complaint response, the Council said Y’s visit to Ms X had not been arranged by officer 1.
33. A case supervision record dated 19 July records there had been a preconference discussion with the ICPC chair on 14 July, who considered the case could be managed through a child in need (CIN) plan, following which the ICPC had been cancelled. Ms X said she was only told about the cancellation on 17 August, the day before the ICPC was due to take place. I have seen no record of this contact.
34. Council records stated that on 4 August, Y refused to meet officer 1 face-to face but agreed to an online meeting. There is no record of the discussion with Y.
35. The Council provided a copy of the CIN plan in response to our enquiries. The plan states:
• it started on 4 August 2022;
• “[Y] is aware of the plan and has not made any comment”. Ms X disputes this. She said no-one spoke to Y about the plan; and
• “Both parents have agreed to the plan”. Ms X said she was not sent a copy of the plan at that time. The Council accepted there was no record to show it sent the plan to her.
36. The CIN plan records the following actions to be completed:
• CAMHS would encourage Y to attend appointments;
• a school attendance officer will support Y to improve her attendance, working closely with her school;
• both parents to seek support for their differences and learn strategies to manage these without engaging in behaviours that may be harmful to Y;
• Ms X to have a mental health assessment. The CIN plan stated Ms X’s mental health continued to impact on Y and that Ms X reported she was well supported with a therapist and an Independent Domestic Violence Adviser (IDVA); and
• Officer 1 to provide domestic abuse support to Mr Z around communication techniques and co-parenting with Ms X. The CIN plan records Mr Z did not consider this was needed as he and Ms X were not living together.
37. At the time, CAMHS had an open case, but Y was not engaging. Ms X had reported Mr Z was not encouraging Y to attend appointments as he did not generally consider therapy was helpful. The CIN plan does not record an action to address this with Mr Z, and there is no record of this being discussed with him. There is also no mention of concerns about Y being left alone for long periods or any action around this, such as safety planning. In response to my enquiries, the Council confirmed there was no safety plan or written agreement with Mr Z.
38. Council records state officer 1 completed an assessment and sent a copy to Ms X on 31 August 2022. Ms X raised concerns about comments in the assessment about her own mental health, which had led to the action in the CIN plan about a mental health assessment. In its complaint response the Council clarified that it had concerns about her emotional presentation.
39. On 9 September 2022, officer 1 spoke to Mr Z about their concerns about Y’s very low school attendance record. They recorded Mr Z said he was not able to care for Y because she “was proving to be difficult and does not want to attend school”. Officer 1 also tried to speak to Y, but she refused to speak to them.
40. Following that meeting, officer 1 contacted Ms X and told her that Mr Z wanted Y to return to her care. Ms X agreed to this, but said she wanted a meeting with the professionals involved to agree a clear plan to support Y.
41. An online meeting was arranged for 13 September with Y’s school. Ms X said she was not told Mr Z would be attending the meeting, so she was taken by surprise when he was present. She said the meeting discussed Y’s return to her care, but did not agree any plan to support Y.
42. In its final complaint response, the Council agreed the meeting should have been split and apologised. It said officer 1 said he had tried to create some safety by reassuring both parents they would be muted if not able to conduct themselves appropriately.
43. The Council sent me a written record of the meeting. This states that both parents attended separately due to their “volatile relationship”. It refers to concerns about Y being discussed and the agreed outcome was the case would proceed to an ICPC. This record conflicts with Ms X’s account, and appears to be inaccurate because by September 2022 it was agreed Y would return to live with Ms X and be supported by a child in need plan.
44. A new social worker, officer 2, was allocated to progress the CIN plan. Officer 2 tried to do an unannounced visit to Ms X’s home on 28 September, but no-one was at home. They spoke to Ms X on 6 October and arranged a further home visit on 7 October. Ms X told officer 2 she was unhappy with the way the case had been handled and wanted the case transferred back to Council B.
45. The record shows officer 2 had issues with the Council’s computer system which meant they were not able to make the referral to Council B straightaway. They contacted Ms X on 17 November to arrange another home visit, but Ms X declined this. Officer 2 confirmed the case would be transferred to Council B. This was not completed until 12 December 2022.

Complaints handling

46. Ms X complained on 3 October 2022. The Council responded on 16 November. Whilst it responded to the points Ms X raised, Ms X disputed the account of events set out in the complaint response. She asked the Council to consider the complaint further in mid-January 2023.
47. The Council send a further response on 1 March 2023. At this stage, it accepted it could not verify all the communications officer 1 said they had had with Ms X as these “were not fully documented”. It apologised if she was not kept updated in a timely manner and if matters were not properly explained. It blamed the delay in transferring the case to Council B on Ms X’s lack of engagement with officer 2.
48. Ms X raised further concerns on 10 April and the Council responded on 14 June 2023. In its response, it said:
• officer 1 acknowledged they should have kept Ms X better informed, and apologised;
• officer 1 was satisfied, from his discussions with Mr Z, that there was no concern about how Mr Z was keeping Y safe;
• both the team manager and officer 1 acknowledged Ms X should have been told sooner about Y’s hospital visit in June 2023, for which it apologised. It said there was a misunderstanding as officer 1 understand Y was in contact with Ms X but Y was actually in touch with another relative;
• it was not aware Y had self-harmed following verbal abuse from Mr Z and her paternal grandmother;
• it could not refer Ms X for support from its Keeping Families Together service because Y moved back to Council B’s area, and apologised if that was not explained to her;
• it had addressed the poor case recording with officer 1;
• it accepted there was a delay in transferring the case back to Council B.
49. Ms X told me that she had to do a subject access request (SAR) to obtain the records so she could challenge the Council’s complaint responses.
50. When asked why it had not used the children’s statutory complaints process, the Council was not able to explain this as it said both the complaints officer and complaints manager who had dealt with the complaint have left the Council.
51. It said Ms X did not ask it to escalate the complaint to stage 2 so it had treated her further communications as requests for clarification.

Analysis and my findings

52. There was no undue delay in allocating officer 1 to make enquiries after the Council received two referrals in late April 2022. Officer 1 carried out a home visit on 5 May. Officer 1 progressed the case in June and July, at which point it was decided the case did not meet the threshold for child protection.
53. However, during this period there was a failure to keep proper records of contacts and visits, which was fault. On balance, there was also a failure to keep Ms X properly informed.
54. Ms X has parental responsibility so was entitled to information about Y and to be included in discussions about her care. There is no record she was invited to the meeting with the school on 10 June, although Mr Z was invited but could not attend. There is also no record the Council spoke to her about Y’s hospital admission on the same day. This was fault.
55. Although a child in need plan was prepared, there is no record this was sent to Ms X, which was fault. The plan was supposed to start in early August but by 7 October, when Ms X asked for the case to be transferred to Council B, none of the actions set out in the plan had been progressed. This was further fault.
56. Council records indicate Ms X presented as upset and tearful at a meeting with officer 1. It was appropriate for it to consider her emotional wellbeing and the impact of any mental health issues on Y. It is not my role to say whether the Council was correct when deciding a mental health assessment was needed as part of the actions in the CIN plan. I do not find fault with the Council in relation to this part of the complaint.
57. Ms X raised concerns about Y’s safety with Mr Z as she was concerned Y was being left alone for long periods of time when Mr Z was at work and Y was not in school. On balance, the Council did not take sufficient steps to ensure that Y was being properly cared for in light of these concerns.
58. On balance, the record of the meeting with parents and professionals in September 2022 was inaccurate. In its complaint response, the Council accepted it should have arranged a split meeting in view of the domestic abuse Ms X had reported. The failure to do so was fault, which caused Ms X distress, particularly as she had not been told Mr Z would be present.
59. There was an undue delay in transferring the case to Council B between October and December 2022, which was fault, and the Council wrongly tried to blame Ms X for the delay, which was further fault. The Council should have considered transferring the case in September when Y returned to live with her mother in Council B’s area, rather than waiting for her to request this. As a result, Y did not receive any support from September to December 2022, which was fault.

Complaints handling

60. In its early complaint responses, the Council insisted officer 1 had been in regular contact with Ms X and kept her informed, although the records did not support this. Ms X had to obtain the records in order to challenge the Council’s account. The Council also tried to blame Ms X for the delay in transferring the case to Council B, which is not supported by its records.
61. The Council’s policy says its “responses must be open and honest” and that it will admit fault when things have gone wrong and take steps to put things right. That did not happen on this occasion. In addition, there were delays in responding, and a failure to escalate the complaint to stage 2 when Ms X challenged the earlier responses. On this basis, I find fault with the complaints handling.
62. The Council was not able to explain why it used its corporate complaints process rather than the children’s statutory complaints process. At the start, this case was a child protection case, and outside the scope of the statutory complaints process. However, from July 2022, it was progressed as child in need, which does fall within the statutory complaints process.
63. In any case, statutory guidance and our practitioner guidance say councils should investigate using the statutory complaints process where complaints fall within its scope and should consider investigating all complaints together and provide a single response.
64. Our guidance also says there should be a record made of any decision not to use the statutory complaints process. The Council has no such record in this case. There is, therefore, no indication of its reasons for not using the statutory complaints process for those parts of the complaint that fall within its scope. This is further fault, although this has not caused Ms X a significant injustice as she has been able to complain to us and we have investigated her complaint.

Injustice caused

65. As a result of the Council’s failings, Ms X felt she was not listened to and not kept properly informed about Y. This caused her significant distress, at a time when she was already under pressure as a result of the separation from Mr Z and Y’s decision to live with him. She was also put to avoidable time and trouble pursuing the Council for a proper response to her complaint. And there is uncertainty about whether Y missed out on support from early August to late December 2022, which was an injustice to her.

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Agreed action

66. Within one month of the date of the final decision, the Council will:
1. provide a meaningful apology for the injustice caused by the faults identified. (Guidance on meaningful apologies can be found in our Guidance on remedies, available on our website);
2. pay Ms X £500 for the distress, and avoidable time and trouble caused;
3. and pay Ms X, for the benefit of Y, £250 to remedy the uncertainty about whether she missed support. (This makes a total payment of £750).
67. Within three months of the date of the final decision, the Council will:
1. remind relevant staff of the need to keep a proper record of all actions and contacts, and ensure the records are made as soon as possible after the event to reduce the risk of inaccuracy;
2. remind relevant staff of the need to take concerns about a child or young person’s safety seriously, take appropriate action to investigate and/or address them, and keep a proper record of these steps, including the reasons for not taking action, where appropriate;
3. remind relevant staff of the need to consider split meetings in all cases where domestic abuse is alleged, and record its reason(s) for deciding a split meeting is not needed in relevant cases, including any steps taken to protect those claiming domestic abuse from further harm;
4. ensure staff have access to a clear process for transferring cases to another council, and understand who to contact with any questions or concerns;
5. remind relevant staff of the need to be open and honest, admit mistakes when things go wrong, and take steps to put matters right, in line with its complaints policy;
6. provide training or guidance to relevant staff on when the children’s statutory complaints process should be used, what to do where parts of the complaint are covered by the process, but other parts are not, and the importance of keeping clear records (including the reasons for decisions about which process to use and for not providing a single response to complaints, where appropriate).
68. The Council will provide us with evidence it has complied with the above actions.

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Final decision

69. I have completed my investigation. I have found fault leading to personal injustice. I have recommended action to remedy that injustice and prevent recurrence of the fault.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman