Summary: Miss X complains on behalf of her son, B, about the Council’s response to concerns raised about B’s care and support. Ms X also complains the Council failed to complete actions agreed as part of its complaints procedure. We have found fault with some of the Council’s actions. We have made recommendations to remedy the injustice caused. We have not found the Council at fault for not having a specific strategy for internet safety. We have not investigated whether the compensation already offered by the Council is suitable. The upcoming multiagency investigation is better placed to consider this part of Miss X’s complaint.

The complaint

1. The complainant, whom I refer to as B, is represented in this complaint by his mother, Miss X.
2. Miss X complains about how the Council responded to concerns about B’s care and support, as part of its statutory complaints procedure. Specifically, Miss X says:
1. the Council has continued to unreasonably request she makes formal Subject Access Requests for copies of important, relevant information which it should share with her automatically, such as safeguarding reports and complex needs referrals;
2. the Council has failed to create or implement adequate action plans and strategies to improve services;
3. an Adult Social Care Worker unreasonably delayed in contacting B to build a relationship and ensure his needs were met, despite there being further safeguarding incidents;
4. the Council has failed to take any clear action to offer direct support for young people affected by issues regarding internet safety; and
5. the compensation the Council offered because of the complaint did not take account of the lack of direct payments which should have been offered before B went into hospital.

Back to top

What I have investigated

3. I have investigated parts A to D of Miss X’s complaint. The final section of this statement contains my reasons for not investigating part E of the complaint.

Back to top

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. 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)
6. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.

Back to top

How I considered this complaint

7. I considered information provided by Miss X and discussed the complaint with her.
8. I considered the Council’s responses to my enquiries.
9. Miss X and the Council were able to comment on a draft version of this decision. I considered any comments received before making a final decision.

Back to top

What I found

Background

10. Below is a summary of the key events leading to this complaint. It is not an exhaustive chronology of everything that happened.
11. In early 2018, B was detained in a secure hospital under the Mental Health Act. A process to decide where B should live once discharged from hospital began. In April 2018, B was transferred to another hospital, a specialist unit for children with mental health and developmental conditions.
12. In May 2019, B was considered ready for discharge, but a placement had not been found. In September 2019, the hospital was closed and B transferred to another facility.
13. In July 2020, B moved into a supported-living property, but was quickly recalled to hospital. In November 2020, a suitable placement for B was found.
14. Miss X complained to the Council. The Investigating Officer (IO) agreed a statement of complaint at Stage 2 of the complaints process. Most of the complaints were upheld. Miss X complained the Council had not adhered to a service specification and recommendation from the mental health tribunal about B’s care, resulting in his deterioration and return to hospital. Miss X also complained about a lack of urgency in finding a new placement.
15. Miss X made a further, related complaint about delays in B’s discharge from hospital since early 2019 when he was ready to leave. The IO report upheld the complaint, stating “there were certainly delays in finding a placement” and said these may have affected B’s mental health and that B’s life was “on hold.”
16. The IO also upheld complaints about social care’s attitude, failure to offer respite care, information sharing about an incident, and a lack of recognition of B’s needs and support.
17. In its adjudication letter the Council accepted the IO’s findings. It accepted responsibility for delay to B’s discharge, although it did not state the period for which it accepted responsibility. It offered a remedy of £2,250 to B and £300 to Miss X to cover all the upheld complaints.
18. Miss X asked the Council to escalate the complaint to Stage 3. The Stage 3 Review Panel said the Council should give Miss X information about its placement search and that it should answer her further questions about the placement breakdown. It recommended the Council reconsider the compensation offer made. It also said the Council should provide Miss X with a written copy of its proposed action plan and give a progress report three to six months later.
19. The Council then offered Miss X £2,500 for B and £500 for herself. Miss X approached us as she felt the remedy was insufficient and B had effectively lost two years of his life. She also complained she had not received information on an action plan to improve the service and that B was still receiving inadequate support. She complained of the Council’s delay in contacting her son, as it promised it would do in its final complaint response.
20. A significant part of Miss X’s complaint concerned avoidable delays in B’s care. Miss X said B had not moved into a community placement with a suitable package of care until late 2020. This was despite clinicians determining B did not need to be on an inpatient unit in late 2018.
21. Miss X’s complaint was assessed by the Ombudsman’s Joint Working Team (JWT), which acts on behalf of both the Local Government and Social Care Ombudsman and the Parliamentary and Health Service Ombudsman. The JWT established that multiple organisations were involved in decisions about B’s care. It concluded that while the Council had considered Miss X’s complaint, the other organisations had not.
22. The JWT proposed a multi-agency investigation, led by NHS England, should properly consider this aspect of Miss X’s complaint. The Ombudsman would separately consider the Council’s actions following the statutory complaints procedure. This process established the scope of this investigation, as outlined in paragraph 2.

Analysis

Complaint about access to information

23. Complex Needs Panels help make decisions about individual services and support for those with complex needs.
24. The stage three Review Panel recommended that information presented to the Complex Needs Panel, and information given to providers when seeking placements, be shared with parents routinely. It also recommended the Council consider providing parents with minutes from Complex Needs Panel meetings.
25. In its final response to Miss X, the Council said it would not accept this recommendation. It said the information recorded on the file belonged to B and the Council had to take B’s view into account. It said if B wanted to request and share his records, he would be able to do so. The Council did say it felt Complex Needs Panels could be more transparent than they were. It said it would discuss this with the Chair of the Complex Needs Panel.
26. Responding to my enquiries, the Council said it had appointed a new Chair of the Complex Needs Panel and the Panel’s terms of reference were being reviewed. This was to incorporate how the Complex Needs Panel shared its decision-making with parents and carers. It said this was ongoing work.
27. The Council has responsibilities as a data controller, in line with General Data Protection Regulations (GDPR), concerning how it can disclose data. It is right of the Council to be mindful of these responsibilities. The Information Commissioner’s Office (ICO) would be best placed to consider individual complaints about the Council’s decision on whether to disclose specific records.
28. Even so, the Council has agreed the Complex Needs Panel could be more transparent in how it makes its decisions. Committing to reviewing the terms of reference of the Panel, to try and release as much information about its decision-making as possible, was an appropriate step.
29. The Council committed to this in July 2021. It has not yet completed this work. The Council said it appointed a new Chair of the Complex Needs Panel, which may account for some of the time taken to carry out this work. However, given it has been more than one year since the Council committed to this, I have found the Council at fault for the time taken to review the Panel’s terms of reference.
30. I believe this fault has caused an injustice. The Council agreed to this action in the interest of greater transparency and to help restore Miss X’s confidence in its processes and decision-making. Not carrying out this action has left Miss X’s concerns unaddressed. It remains unclear what information will be shared with parents and carers as part of this process in the future.

Complaint the Council has failed to create or implement adequate action plans to improve services

31. The Review Panel recommended the Council provide Miss X with its action plan to improve its services, a copy of which had been presented to the panel. It said the Council should also provide Miss X with a progress report between three and six months after this.
32. Responding to my enquiries, the Council said it understood this referred to a review of the Disabled Children and Young People’s Team, which was a commitment shared with Miss X during the panel hearing. The Council said it had completed the review as part of a multiagency partnership and had identified key areas for development. It said:

“…a provisional programme of work is now in place which includes further work in relation to the councils Direct Payments policy, practice and guidance.”

33. The Council also said:

“Further work has been commissioned alongside our Health colleagues to review services for (children and young people) with Learning Difficulties and / or Autism. The outcome of this review will be considered alongside the recommendations within the DCYP review to ensure alignment across the pathway, to maximise resources and improve response times.”

34. It would not be for the Ombudsman to assess the adequacy or impact of the Council’s plan. Our role extends to assessing whether the Council took measurable, relevant action. Additionally, we would seek confirmation the Council has communicated this to Miss X.
35. The Council said it had not given Miss X a copy of the action plan and further reports, as it had not committed to doing this in its stage three response letter. It had however committed to providing her with a more general update on progress and accepted it had not done so. I have found the Council at fault for not providing an update to Miss X, as it said it would.
36. I consider this fault caused an injustice. Again, the Council committed to providing an update to show it had learned lessons and to increase Miss X’s confidence in the service. Not doing this has caused further frustration for Miss X, as well as creating uncertainty over whether the Council had followed through on commitments made at the conclusion of the complaints procedure.

Complaint an Adult Social Care Worker unreasonably delayed in contacting B

37. The Review Panel recommended the Council tell Miss X when a social worker would contact and visit B. In its response in July 2021, the Council said it understood this had already happened. When Miss X approached the Ombudsman in August 2021, she said the Council had not contacted B to build a relationship and ensure his needs were being met. Miss X said this did not occur until October 2021, three months after the complaints procedure.
38. Responding to our enquiries, the Council provided a copy of case notes and said a social worker had made contact in early September 2021. Having reviewed the case notes supplied, I cannot find evidence of this contact. The contact notes provided begin in November 2021 and show discussion about the support B was receiving. There is no clear direct contact with B, although Miss X is copied into correspondence between B’s social worker and other staff. The records suggest the Council did make contact, but it is not clear when this happened.
39. From the Council’s response to our enquiries, it is clear B was not contacted in or around July 2021, as is suggested in the Council’s response at the time. On a balance of probabilities, I believe it likely the Council did not contact B directly until some point in October 2021. This would be around three months after the complaints procedure was concluded.
40. I have found the Council at fault for this delay in contacting B and updating Miss X. This fault caused an injustice to Miss X and to B. Again, the Council committed to this action during the complaints procedure and, given the nature of the complaint, I would consider that engaging with B at the earliest possible opportunity would have been a priority. Not doing so caused further frustration and uncertainty for Miss X, and likely caused uncertainty for B.

Complaint the Council has failed to take any clear action to offer direct support for young people affected by issues regarding internet safety

41. During the stage three review, Miss X said the Council had been slow to address identified risks associated with B’s internet addiction, although this had improved as time went on. Miss X said internet addiction was more recognised now and sought information about whether the Council had taken any steps to address this as a wider issue.
42. The Review Panel recommended the Council share with Miss X its current policy for dealing with inappropriate internet use and/or addiction, and confirm whether this was due to be reviewed. In its stage three response, the Council provided links to online information and training courses that were publicly available to professionals and parents on its affiliated webpages. When referring her complaint to us, Miss X said the Council had taken no clear action to support young people affected by risks arising from internet safety.
43. Responding to our enquiries, the Council confirmed there was no internal guidance or standalone policy about managing risks posed to vulnerable individuals from inappropriate internet use. It referred to the information it had already highlighted in its response to Miss X. It said professionals involved in B’s care had identified general risks around B’s internet use as part of his care and support.
44. I consider the Council adhered to the Review Panel’s recommendation by signposting to relevant information in its response. There is a general expectation the professionals involved in an individual’s care would put in place actions to address risks identified as part of an individual’s care and support plan. This might include risks arising from internet addiction.
45. The Council’s response suggests the guidance is available to staff or practitioners if they choose to access it. I have not identified a requirement for the Council to have a standalone policy or strategy related to risks posed by internet addiction. I have not therefore found fault with the Council’s actions.

Back to top

Agreed action

46. Within four weeks of the final decision being issued, the Council has agreed to:
1. apologise to Miss X in writing for the faults identified in this statement and for the injustice these faults have caused; and
2. pay Miss X a total of £350, comprised of the following:
• £250 to recognise the frustration and uncertainty caused by the Council failing to complete agreed actions after the complaints procedure; and
• £100 to recognise the avoidable frustration caused by pursuing this complaint further.
47. To avoid any doubt, this payment is in recognition of the injustice arising from the Council’s failure to fully complete actions agreed as part of its complaints procedure. This payment would therefore be in addition to the compensation offered to B and Miss X by the Council, for injustice it had already identified. As part of my investigation, I have not considered whether the compensation of £2500 and £500 the Council already offered is suitable. This is something the multiagency investigation would be better placed to consider, as outlined at the end of this statement.
48. Within 12 weeks of the final decision statement being issued, the Council has agreed to:
1. produce the revised terms of reference for information sharing at Complex Needs Panels and share this with Miss X; and
2. set out in writing to Miss X the conclusions of the review into the Disabled Children’s and Young Person’s Team. This should explain the measures it has now implemented to improve services and outline any further measures it proposes to take.
49. The Ombudsman will seek evidence of the Council’s compliance with agreed recommendations.

Back to top

Final decision

50. I have completed my investigation with a finding of fault by the Council, causing injustice. I have made recommendations to remedy the injustice caused.

Back to top

Parts of the complaint that I did not investigate

51. I have not investigated part E of Miss X’s complaint, about whether the compensation the Council offered is suitable and accounts for a lack of Direct Payments. This is because the multiagency investigation will consider the actions of each agency involved in making decisions about B’s care, including the time taken to find a suitable placement for B. The outcome of this investigation is likely to have a bearing on the amount of compensation awarded.
52. If Miss X remains dissatisfied with the outcome, following the conclusion of the multiagency investigation, she can ask the Ombudsmen to consider this matter.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman