Summary: Ms X complains the Council did not properly safeguard her and her children. Ms X says the Council failed to recognise the impact of this, despite her complaints being upheld by the statutory complaints process. The Ombudsman finds fault with the Council for its actions during the statutory complaints process. The Council has agreed to pay a financial remedy and carry out service improvements.

The complaint

1. Ms X complains the Council failed to properly follow safeguarding procedures with her and her children.
2. Ms X complains the Council had evidence of this and upheld it during the complaints process but has failed to address the impact on her and her children or carry out meaningful actions to address this.
3. Ms X says the Council’s failure to act following the upheld complaints means that she and her children continue to be at risk of harm and are still suffering from the distress caused by the Council.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. We cannot investigate a complaint about the start of court action or what happened in court. (Local Government Act 1974, Schedule 5/5A, paragraph 1/3, as amended)
6. 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)
7. 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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What I have and have not investigated

8. Part of Ms X’s complaint is that the Council’s suppression of evidence led to the children being removed from her and placed with an unsuitable guardian.
9. I cannot investigate this part of Ms X’s complaint. The care and contact arrangements of her children have been discussed during court proceedings and a court order is in place. If Ms X disagrees with this action, she should challenge it in court. Only the courts can determine if the care order in place should be changed. I will therefore only consider the parts of Ms X’s complaint that are separate from court matters and have been considered through the complaints process.

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How I considered this complaint

10. I considered Ms X’s complaint to the Council and information she provided. I also considered information from the Council.
11. I invited Ms X and the Council to comment on a draft of my decision and considered any comments received.

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What I found

Statutory complaints procedures

The three-stage process

12. 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.
13. The first stage of the procedure is local resolution. Councils have up to 20 working days to respond.
14. 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 investigate the complaint and an independent person (IP) who is responsible for overseeing the investigation and ensuring its independence.
15. 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.
16. 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.
17. 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.

No reinvestigation if process complete and not flawed

18. The statutory children’s complaints procedure was set up to provide children, young people and those involved in their welfare with access to an independent, thorough, and prompt response to their concerns. Because of this, if a council has investigated something under the statutory children’s complaint process, the Ombudsman would not normally re-investigate it.
19. However, we may look at whether there were any flaws in the stage two investigation or stage three review panel that could call the findings into question. We may also consider whether a council properly considered the findings and recommendations of the independent investigation and review panel, and whether it has completed any recommendations without delay.

What happened

20. Ms X has two children. The Council had concerns for the wellbeing of Ms X’s children and asked Ms X’s ex-partner to care for them.
21. Ms X complained to the Council. In her complaint she said

• The Council had failed to properly consider safeguarding concerns about her children.
• The safeguarding assessment by the Council did not take full account of the evidence, including the history of domestic abuse towards her from her ex-partner.
• Ms X had lost her trust in the Council because of it failing to safeguard her and her children.

22. The Council considered Ms X’s complaint under the statutory complaints process. At stage two, it appointed an independent person (IP) and Independent Officer (IO) to consider Ms X’s complaint.

Stage two investigation

23. The stage two investigation upheld or partially upheld that;

• The Council had not properly considered the safeguarding concerns for the children raised by Ms X and had removed parts of the children’s disclosures from reports.
• There was a breach of professional standards and suppression of evidence from the social worker.
• The assessment carried out by the social worker did not properly consider the risk to the children or take full account of the evidence available.
• The Council did not properly consider the risk posed to Ms X by her ex-partner and had minimised his behaviour and past abuse towards Ms X.
• The Council had delayed arranging and providing the support that it said Ms X needed to have contact with her children.
• The Team Manager had spoken about Ms X inappropriately to other officers.
• There had been poor communication and mixed messages from the Council to Ms X.

24. There were several parts of the complaint the stage two could not consider as they were related to matters being decided in court. These centred around contact and care of the children, which was subject to court proceedings.
25. The recommendations from the stage two investigation were;

• To provide Ms X with outstanding reports and meeting minutes.
• To refund Ms X for her outstanding costs for contact with her children.
• Arrange for the agreed therapeutic support for Ms X.
• Provide a formal apology to Ms X from the service manager for inappropriate comments.
• Provide a full apology to Ms X for the fault found.
• Review the assessment of the children’s current carers to consider of the history of violence.
• Consider transferring the case to another team.
• Ensure managers and staff are trained in domestic abuse.
• Provide refresher training for staff on Working Together to safeguard children.
• Consider taking action on the staff member for interference with case records.
• Consider an audit of the children’s files.

26. According to the statutory complaints process, the Council should have issued an adjudication letter to Ms X, explaining its final findings and decision. The Council did not issue a stage two adjudication letter.

Stage three review panel

27. Ms X remained unhappy and asked the Council to consider her complaint at stage three.
28. The Council held a stage three review panel. The panel noted there had been no stage two adjudication from the Council and it had therefore not accepted the findings of the report or taken responsibility for the fault found. The Council told the panel the person responsible for issuing the adjudication letter was currently on long term leave.
29. The panel also highlighted there were outstanding actions from the stage two. This was in part because the case had progressed to family court to decide the suitable guardian for the children.
30. The stage three review panel’s overall findings upheld all the findings of the stage two investigation and highlighted the Council had failed to comply with some of the recommendations or provide the adjudication letter. It told the Council “the panel were greatly concerned about the inherent poor standard of practice unearthed by the investigation which ranged across the entire child in care team”. It also highlighted concerns about some staff who had suppressed or minimised information, and that the Council had placed the children with Ms X’s ex-partner with little investigation and consideration into their history of violence.
31. The panel recommended;

• Robust management oversight of social work activities.
• Mandatory training for the children in care team on domestic abuse and a review of child protection procedures.
• The Council provide the outstanding apology to Ms X.

32. The Council sent a stage three adjudication letter Ms X in March 2024. In the letter it told Ms X that it agreed with the findings and recommendations from the Panel. It did not provide a remedy for the injustice to Ms X.
33. The Council later sent Ms X the stage two adjudication letter and apology from the team manager, as this was an outstanding action from the stage three panel. In the letter, the Council apologised to Ms X for what she had experienced and offered her “£500 as a gesture of goodwill”.
34. Ms X remained unhappy and bought her complaint to the Ombudsman.

Analysis

35. As set out in paragraphs 18 and 19, the Ombudsman will not reinvestigate the substantive matters of complaint unless there is reason to believe that the way the stage two investigation or stage three review considered the complaint is flawed. However, we will consider if the Council properly considered the findings.
36. It is clear from the Council’s records that a thorough investigation was carried out at stage two, and the findings and recommendations upheld at stage three. I am satisfied the review panel conducted a robust review of the stage two, taking account of the evidence presented by the IO, IP and the Council. The reasoning in the review panel report for the findings are clear, justified and well explained.
37. I see no good reason to reinvestigate the substantive parts of Ms X’s complaint as the considerations of it by the stage two investigation and stage three panel are without fault.
38. However, the Council failed to recognise the findings at stage two and accept responsibility for the maladministration by adjudicating the stage two findings when it should have done.
39. I echo the stage three findings about the Council’s failure to provide a stage two adjudication letter. While I accept the Council did later send a stage two adjudication letter, it should have provided this after the stage two investigation, and not to do so is fault.
40. The Council’s stage three adjudication letter accepts responsibility for the failings found by the panel, however, it failed to apologise to Ms X or consider a remedy for the injustice caused to her. Given that most of Ms X’s complaints were upheld or partially upheld, the Council should have considered whether a remedy was suitable at this point.
41. I asked the Council why it had not provided a remedy in its stage three adjudication. It told me that it had sent the stage two adjudication after the stage three, which recognised the injustice to Ms X and offered her a remedy.
42. If the Council had carried out the statutory actions, this remedy would have been offered to Ms X at the end of the stage two. Any remedy at this point would not consider the further distress and injustice caused to Ms X by the Council’s failure to properly engage with the complaints process or carry out the actions recommended.
43. The Council’s poor engagement with the adjudication process means it delayed accepting responsibility for its actions. It has also delayed putting in place the service improvements for others, and remedying the injustice to Ms X.
44. The £500 that should have been offered at the end of the stage two is not a reasonable remedy to address the further injustice identified during the stage three. For this reason, the Council should provide Ms X with a further financial remedy in recognition of this.

Consideration of domestic abuse

45. Part of Ms X’s complaint is the Council continues to put her at risk, despite the complaints process upholding her concerns about domestic abuse. This is in relation to Ms X’s ex-partner during contact with her children.
46. The Council has told me that it has no reason to believe there is currently a risk to Ms X or the children. The current arrangements are that the contact centre facilitates the pickup and drop off the children, and Ms X’s contact is supervised. The Council has investigated the allegations of risk that were raised during the complaints process, and no professionals have raised any further concerns. There is a care order in place for the children to remain with Ms X’s ex-partner and his family, and the plan in place is to support with the current contact arrangements.
47. The current contact arrangements and care order for Ms X’s children are set by the court. The Council has explained its considerations of whether the current arrangement poses a risk to Ms X and has decided it does not. If Ms X disagrees with the arrangements, the court is the best place to address this.
48. I have considered whether there is further fault by the Council in its understanding of domestic abuse. The stage two and stage three identified that staff had a poor understanding of its complex nature and had minimised concerns. The recommendations from the panel were to carry out compulsory training for all staff. When I asked the Council if it had carried out this recommendation, it said that social workers receive training at university and there were further weekly sessions that staff could attend. This does not satisfy me the Council has understood the gravity of the concerns raised by the panel. The panel were clear the training social workers receive at university was not enough to address the concerns identified during the investigation, and that further training should be compulsory.
49. However, the Council has also said that in light of the concerns raised by the panel, it is currently carrying out a full domestic abuse review to better support its understanding. The Council has said this will be reviewed by the Domestic Abuse Partnership Board to ensure that learning and training is given across staff and partners. I am therefore satisfied the Council has taken the steps to address the concerns raised by the panel. I will not make further service improvement recommendations as the Domestic Abuse Partnership Board is better placed to identify specific issues and training needs.

Reasonable adjustments

50. Part of Ms X’s complaint to the Ombudsman was the Council failed to consider her request for reasonable adjustments during the complaints process.
51. In response to my enquiries, the Council set out what requests for reasonable adjustments Ms X had made, and the requests it had agreed to. It also said it had told her that any new workers with Ms X will be advised of the need to familiarise themselves with Ms X’s reasonable adjustments when communicating with her.
52. I am satisfied with the Council’s actions and do not find fault on this part of the complaint.

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Agreed action

53. Within four weeks the Council has agreed to

• Write to Ms X and apologise for the fault found. The Council should give regard to our guidance on how to make an effective apology.
• Pay Ms X a further £250 in recognition of the distress and injustice caused.
• Review how it will ensure that adjudication letters are sent in line with the statutory complaints procedure.
• Review how it will ensure that it considers our guidance on remedies for upheld complaints.

54. The Council should provide us with evidence it has complied with the above actions.

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Final decision

55. I have completed my investigation. I find fault with the Council for failing to carry out its duties under the statutory complaints process.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman