Hertfordshire County Council (22 011 513)
- The complaint
- The Ombudsman’s role and powers
- How I considered this complaint
- What I found
- Agreed action
- Final decision
The Ombudsman's final decision:
Summary: Miss X complained the Council failed to ensure her daughter, Y, received education in line with an Education, Health and Care plan and delayed in reviewing that plan. We upheld these complaints finding that Y had suffered a significant loss of service as a result. The Council has accepted these findings. At the end of this statement, we set out action the Council has agreed to take to remedy that injustice.
The complaint
- I have called the complainant ‘Miss X’. Her complaint concerns the service provided by the Council to her daughter, ‘Y’, who has special educational needs. Miss X complains the Council:
- failed to provide education to Y in line with an Education, Health and Care Plan (EHCP) issued in August 2020;
- delayed in later reviewing that EHCP.
- Miss X says because of these failings Y’s education has been significantly adversely affected. Miss X also says that she has suffered distress because of the lack of effective communication by the Council over Y’s education.
The Ombudsman’s role and powers
- 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)
- The law says we cannot normally investigate a complaint when someone can appeal to a tribunal about the same matter. However, we may decide to investigate if we consider it would be unreasonable to expect the person to appeal. (Local Government Act 1974, section 26(6)(a), as amended)
- The First-tier Tribunal (Special Educational Needs and Disability) considers appeals against council decisions regarding special educational needs. We refer to it as the SEND Tribunal in this decision statement.
- 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)
How I considered this complaint
- Before issuing this decision statement I considered:
- Miss X’s written complaint to the Ombudsman and any supporting information she provided;
- correspondence between Miss X and the Council which pre-dated our investigation of her complaint;
- information provided by the Council in response to my written enquiries;
- any relevant law or guidance referred to in the statement below.
- I also gave Miss X and the Council opportunity to comment on two draft versions of this decision statement. I took account of any comments they made and any further evidence they provided before finalising the decision statement.
- We have an information sharing agreement with the Office for Standards in Education, Children’s Services and Skills (Ofsted). Under the terms of that agreement I will share this decision with Ofsted before publication on our website.
What I found
Some relevant law and guidance
- A child with special educational needs may have an Education, Health and Care Plan (EHCP). This sets out the child’s needs and arrangements to meet them. The EHCP has different sections. We cannot direct changes to the sections about education or name a different school or education setting. Only a SEND Tribunal can do this.
- The Council is responsible for putting into place the arrangements specified in the EHCP. We can look at complaints about this, such as those which say a child has not received the support set out in their EHCP, or where there have been delays in providing that support.
- The procedure for reviewing and amending EHCPs is in legislation and government guidance. Within four weeks of a review meeting, a council must notify the child’s parent of its decision to maintain, amend or discontinue the EHC plan. (Section 20(10) Special Educational Needs and Disability Regulations 2014 and SEN Code of Practice paragraph 9.176)
- Where a council proposes amending an EHC plan, it must send the child’s parent or the young person a copy of the existing (non-amended) plan and an accompanying notice detailing the proposed amendments. (Section 22(2) Special Educational Needs and Disability Regulations 2014 and SEN Code paragraph 9.194)
- Following comments from the child’s parent or the young person, if the council decides to continue to make amendments, it must issue a finalised version of the amended EHC plan as soon as practicable. In any event this should be within eight weeks of the date it sent the EHC plan and proposed amendments to the parents. (Section 22(3) SEND Regulations 2014 and SEN Code paragraph 9.196)
- For young people moving from secondary school to a post-16 institution or apprenticeship, the review and any amendments to the EHC plan – including specifying the post-16 provision and naming the institution – must be completed by the 31 March in the calendar year of the transfer.
- Parents have a right of appeal to the SEND Tribunal if they disagree with the special educational provision or the school named in their child’s EHC plan. They can only appeal after receiving a final amended plan.
Chronology of key facts
- Y is a young person now aged 17 and from September 2023, in year 13 of her education. This complaint considers Y’s education provision from September 2020 (when she began year 10) up to July 2023 (the completion of year 12).
- Y has special educational needs. She has an autistic spectrum disorder with a pathological demand avoidance profile. She experiences anxiety and difficulties with social communication. She has experienced much disruption with her education which pre-dates the events investigated here.
- The Council issued Y with an EHCP in August 2020. Among other matters this said the following:
- that she would receive education other than in school for at least three terms; to be reviewed every half-term;
- that she would receive eight hours a week as an online home learning package;
- that she would build a trusted relationship with a named worker, whom I will refer to as a mentor. After a gradual process of introduction, the mentor would aim to visit Y for three times a week for at least 30 minutes duration during the autumn term. These visits would increase to three visits of one hour a week by the spring term;
- that from the spring term the mentor would help prepare Y for transition to a named education setting where they would introduce her to “another named adult”;
- that by the summer term Y would receive some education outside the home; with the aim of receiving up to 14 hours a week education;
- that “steps forward will be continually planned and monitored to ensure momentum and progress towards [Y’s] goals which may, for example, be transition to school or college or to taking part in an [..] equivalent course the next academic year at [a named education setting]
- that Y would receive interventions from a speech and language therapist.
- Miss X has provided a June 2020 report produced by the Headteacher of the education setting. The content of this report helped inform the content of the EHCP. The report said the education setting could provide Y with a mentor and she could gradually attend its building to begin studies. It suggested various alternatives for how it could deliver Y’s education with different combinations of on-site or off-site tutoring. The Headteacher’s report said that he believed the education setting could meet Y’s needs and support her re-integration into an education setting.
The 2020/21 academic year
- I asked the Council to provide me records of how it reviewed Y’s progress during the 2020/21 academic year.
- First, it provided me records from the mentoring service who supported Y. The Council commissioned this service from an education consultancy – not the named education setting. The mentor’s notes showed:
- they first visited Y at home in September 2020. It took several weeks before Y could engage directly with the mentor;
- from November 2020 Y and her mentor would leave home and go on short journeys outside the home (such as to local shops) accompanied by Miss X;
- that in January 2021 visits stopped although Y met with her mentor regularly online and from April 2021 at her home. They had weekly sessions and the mentor recorded these lasting two hours;
- by May 2021 there were references to Y leaving the house with her mentor. It was not until August 2021 the mentor referred to Y feeling confident to meet her alone, without Miss X also present.
- In these records there was little reference to Y discussing her education needs with her mentor. In December 2020 the mentor recorded Y saying she wanted to go back to school. They recorded asking Y and Miss X if they “had spoken to the relevant people” and “they told me they had not yet”. In April 2021 they recorded a conversation about Y’s progress with her online studies.
- Second, the Council has provided a record to show a caseworker helped obtain a laptop for Y in September 2020. It has also provided copies of reports from Y’s online education provider from December 2020 and at the end of the school year.
- Third, the Council provides a record of a visit to Miss X in June 2021 from its SEND Specialist Advice and Support Service, in which Y could not take part. The service recorded Y received around one hour a week support from her mentor and two hours a week online tuition. The online provider also gave Y homework. Miss X said that she considered Y could manage more online tuition. Miss X said Y did not want to go to the education setting mentioned in the August 2020 EHCP but did sometimes talk of wanting to go to college.
- From July 2021 Y began to receive speech and language therapy. The Council apologised to Miss X that it did not source this sooner, recognising it was part of Y’s EHCP from August 2020. It said the fault lay with the service commissioned to provide the therapy where there was “miscommunication".
- At no point during the academic year did the Council review Y’s EHCP.
- In general comments in reply to Miss X’s complaint the Council has said that concerning Y transferring to the education setting mentioned in her EHCP:
- it had no obligation to arrange this as Y’s EHCP envisaged preparation for Y’s attendance at the education setting. It did not require her attendance there;
- that Y was not ready for transition in spring 2021. At the time she was still building relations with her mentor.
2021/22 Academic year
- In September 2021 Y asked her mentor if she could visit the education setting named in her August 2020 EHCP. The mentor checked with the education setting. It told her the Council had to make a referral.
- The Council says that also in September 2021 it held an annual review of Y’s EHCP. However, Miss X provides evidence which shows this review took place in November, not September, 2021. Before the meeting Miss X sent a message to the Council concerned there had been a decrease of Y’s online hours of tuition rather than the hoped for increase.
- In November 2021 Y’s mentor recorded that Y engaged well with sessions which were weekly and usually of two hour duration. They would visit nearby shops or restaurants. The mentor recorded: “Last few sessions we had discussed [Y’s] education and her next steps. Mum had messaged me to say that there had been a review over half term and that mum had asked for more hours. When I arrived we discussed this and Mum had said that she had been told the session content was the same each week […] I have been trying to encourage ‘Y’ to think about her next steps”. The mentor ended this note by saying they wanted the next session with Y to focus on education work.
- But Y then cancelled the next two sessions with the mentor who said she would ‘back off’ from trying to do education work with Y and focus on her functional skills. By January 2022 the mentor recorded some frustration Y would not agree to change the content of the sessions.
- In January 2022 the Council wrote to Miss X saying that further to the September 2021 annual review meeting it would amend Y’s EHCP.
- In February 2022 there was discussion between Y and her mentor about Y attending college and potential qualifications. After that Y’s mentor recorded other occasional conversations with Y about her education but noted a withdrawal from her in March. The mentor made their last note in April 2022, which described Y withdrawing from support. Miss X also describes relations with the mentoring service breaking down around this time. Later, in May 2022, she met with the Council’s Special Advisory Teacher and set out concerns with the mentoring service’s approach.
- The speech and language therapy service discharged Y in March 2022 saying it had completed the actions set out in her EHCP. Also in March 2022, the Council issued a draft amended EHCP for Y. Miss X asked later that same month for changes.
- In April 2022 Miss X had communications with the Council over Y’s education moving forward. She wanted to know if the Council had agreed Y should have support through an online provider or attend the named education setting referred to in the August 2020 EHCP. At the end of the month the Council told Miss X that Y’s case worker was changing and that it proposed naming the online provider in Y’s amended EHCP.
- In June 2022, a meeting took place attended by Miss X, Council education officers and a representative from the online provider. The Council said it would still be consulting the named education provider referred to in the August 2020 EHCP. The online provider reported on Y’s engagement with its service. The Council said it was looking to provide a new mentor for Y. It has provided an email showing it made an enquiry with another mentoring service in July 2022 to see if it could support Y.
- By the end of the academic year the Council had not issued a final amended EHCP for Y.
- In general comments the Council has said there was discussion in late 2021 about Y attending the education setting referred to in her August 2020 EHCP. But this was too late to be of benefit to her. This was because she had only two terms left when she could attend (as the education setting does not provide post-16 provision).
2022/23 academic year
- The Council records that in August 2022 one of its SEN officers spoke to Miss X. Their note recorded that, at that time, Miss X did not want the Council to search for an alternative mentor for Y.
- In October 2022 the Council held a meeting to review Y’s EHCP. As well as an officer from the SEN service, Miss X and a representative of the online provider attended. After the meeting, it was agreed a further meeting was needed to complete the review of Y’s EHCP, which followed in November 2022. Nobody from the Council attended that later meeting.
- There are two reasons put forward why the meeting was split this way. First, the Council and Miss X have said the online provider failed to produce a report on Y’s progress until the day of the meeting in October. So, Miss X needed time to consider its content. Second, the Council has also provided an email showing that soon after the meeting the online provider contacted it, asking for a second meeting further to discussions it had with Miss X.
- In between these two meetings the Council issued an amended version of Y’s EHCP, further to the November 2021 review. This contained references to Y engaging well with her mentor, despite that relationship having broken down by April 2022. In Section F, it set out the same plan for Y’s education over three terms as that version issued in August 2020 (see paragraph 19). It contained references to the same education setting that Y could now no longer attend because of her age.
- The Council did not write to Miss X after the October and November 2022 review meetings to confirm if it would further amend Y’s EHCP. However, during this investigation the Council confirmed this was its intention.
- The Council has commented that further to its conversation with Miss X in August 2022, it understood she did not want mentoring services to resume for Y. However, Miss X disputes this and discussed mentoring with Y’s online education provider around the time of Y’s annual review. I also noted that in December 2022 the Council made enquiries with a mentoring service to see if it could provide a service to Y. It next made enquiries in April 2023. By the beginning of May 2023, the Council had secured the service of another mentor for Y who began work with her the following month.
- In mid-February 2023 Miss X received an amended EHCP showing the changes the Council proposed. This contained amendments from the October 2022 version. It proposed striking out references to Y engaging with her mentor and the education setting named in the August 2020 version. It proposed similar levels of engagement with a mentor and online education as before, but removed references to goals on a term-by-term basis.
- Around this time the Council had received contact from Y’s online provider expressing concern that Y might be deregistered from its service. It requested a further urgent meeting with the Council to discuss. I noted that from November onwards both Miss X and the online provider made the Council aware of some tension between them. These centred on the specific modules the provider taught Y who had disengaged from teaching in some areas because of the anxiety this caused her. Miss X considered the provider had gone back on certain assurances about how it would support Y and this had contributed to her anxiety. Different Council officers spoke to Miss X in February 2023 and their notes say she did not want Y enrolled with a different provider at that time.
- The Council had a further meeting with Miss X in late March 2023, by which time Y had disengaged completely from her online provision. Miss X said she had bought some alternative online provision for Y, so she had some education she would engage with.
- In April 2023 the Council said it would search for an alternative provider for Y. It said it would try and identify tuition for Y “with the view to her starting college in September 2023”.
- By early May 2023 a tuition service was in place for Y. However, the provider said that to date Y had not engaged with it.
- Also in May 2023 Miss X enquired with the Council about an alternative online provider for Y. She received no reply to that enquiry until August 2023 when the Council explained it was not a provider with which it had previously commissioned services. It offered to look into doing so, if this was something Miss X wanted to pursue.
- By the end of July 2023, the Council had not issued a final amended EHCP for Y, further to the draft issued in February. However, Miss X did receive a further draft version of the EHCP in late August, containing more proposed amendments. She has sent the Council comments on this.
My findings
The 2020/21 academic year
- I consider the EHCP Y had from August 2020 provided a framework to help guide her transition from education at home to returning to an education setting. I agree with the Council that it did not place a strict requirement that Y would join the education setting named in the document. Instead, it set out the hope Y would be ready for a place at that setting by September 2021 and the background report provided by Miss X supports this finding. Clearly the education setting thought in June 2020 it could potentially help Y with a gradual integration to its provision.
- But the EHCP contained more than statements simply expressing hope or aspirations for Y. It set out some clear measurable steps to help support this hoped-for transition. Specifically, the EHCP said:
- Y would receive eight hours a week online tuition as a minimum. There was a target she would receive 14 hours a week tuition by the end of the academic year;
- Y would receive mentoring of around one and a half hours a week to begin with, rising to three hours a week over the course of the academic year;
- that there would be regular reviews of Y’s progress against these objectives and consideration of her choices from September 2021 onward. Reviews would take place approximately every six weeks (twice a term).
- The Council failed to ensure any of these targets was met.
- The June 2021 document completed by the SEND Advisory service shows that by the end of the academic year Y only received around half the education tuition it was envisaged she would receive (I make some allowance here that some of Y’s teaching involved homework). She received no education outside the home.
- Y’s mentoring, while regular, did not increase over time and did not reach the three hours a week envisaged in the EHCP. It was only ever delivered once a week and not multiple visits a week as set out in the EHCP.
- But most crucially, the Council failed to review the EHCP on the regular basis it should have. It received regular updates from Y’s mentor and some updates from her online provider. But there is no evidence that it used this information to inform any regular reviews of Y's progress, even to a lesser extent than set out in the EHCP. At no point did it take up with the online teaching service or the mentoring service individually the work they undertook with Y and how this might be increased to meet the targets set out in the EHCP. From reading the mentoring notes it is not clear that Y's mentor understood how the EHCP related to their service at all.
- In addition, Y’s EHCP set out that she should receive speech and language therapy during the academic year. But this did not begin until the very end of the academic year, eleven months after the issue of the EHCP.
- I must find fault therefore for this series of failings by the Council.
The 2021/22 academic year
- Throughout this year the Council should have continued to deliver Y’s education in line with her August 2020 EHCP. While parts of it became out-of-date, the Council still needed to ensure Y received support with online tuition, mentoring and planning for her post-16 future.
- While the Council arguably took more involvement in Y’s case during this academic year – holding an annual review and proposing changes for her EHCP – these actions still fell far short of the sort of active, regular, ongoing monitoring Y’s education required. While Y continued to receive both online tuition and mentoring for another two terms, the problems I highlighted from the previous year continued. Both services were delivered on a lesser scale than set out in the August 2020 EHCP. Her plan contained what were now a series of out-of-date objectives, which in any event the Council was failing to measure her progress against.
- In addition, the Council was at fault during this year because:
- it held Y’s annual review late (given none had taken place throughout the previous academic year);
- took far too long to confirm it would amend the EHCP further to that review (around two months instead of four weeks);
- issued an amended EHCP late (around five months instead of four weeks); and
- failed to issue a final EHCP at all within the academic year (taking 12 months instead of 12 weeks).
Academic Year 2022/23
- Sadly this pattern of fault in the management of Y’s case continued into a third academic year.
- The Council finally issued an updated EHCP for Y in October 2022. But this was based on the November 2021 annual review and issued so late, the next annual review cycle had already begun. The document contained references to the mentoring service Y no longer used and an education setting she could not attend because of her age.
- I make no criticism of Y’s annual review spanning two meetings in Autumn 2022. Two reasons have been put forward for why this was. I do not consider it necessary to explore either of these in more detail, as either reason would explain adequately why a second meeting was needed.
- But thereafter, the Council again fell far short of the legal target of four weeks for completing amendments following the review. The Council failed to confirm its intention to amend and then took around 17 weeks to send a draft amended EHCP to Miss X. And at the end of the school year, some ten months after the truncated review, Miss X still waited to receive a final amended version.
- I recognise that during this time the Council has shown a greater level of engagement with Y’s education than in the previous two years. In particular between February and April 2023 the Council undertook a series of meetings and discussions with Miss X around Y’s education and tutoring needs. I am satisfied it acted in good time to identify an alternative education provider for Y from April 2023 when it was clear her relationship with the previous provider had ended. It also re-engaged with the search for a mentor from this time. It made both services available to Y for the summer term 2023.
- Y’s subsequent engagement with those services has been limited. But I am satisfied that this is because of her special educational needs. I consider Y need not have been in the position she found herself in by April 2023, had the Council shown a greater vigilance to her needs over the proceeding years. But at the same time, it is difficult for me to see what more it could do to meet her needs at that specific time given Y’s needs mean it takes time for her to establish trust with professionals.
- I also find there was some fault in the Council’s actions before April 2023, over and above its failure to issue her amended EHCP in good time. First, it did not engage with the disagreement between Miss X and Y’s online provider between November 2022 and February 2023. It missed a potential opportunity to repair relations between the two and avoid further disruption to Y’s education. I also consider that it must have been apparent no later than December 2022 that Miss X still wanted Y to receive support from a mentor, whatever the Council’s understanding of the conversation it had with her the previous August. Further the Council took three months to reply to Miss X’s request for consideration of an alternative online provider for Y, which created an avoidable source of frustration.
- I find there have been service failings therefore during the most recent academic year. Although because I find these have been less in scale and degree, I take a different approach towards the injustice caused to Miss X and Y and my consequent recommendations.
The injustice caused to Y and Miss X
- The primary injustice in this case is to Y. For two years she experienced a wholly unacceptable level of support with her education from the Council. I find it particularly regrettable that even when faced with opportunities to improve its service to Y, such as following annual reviews, the Council failed to take the active interest in Y’s case that it should have done. All this also happened at a pivotal time in Y’s life, as she turned 16 and beyond. Government guidance stresses how important this time of life is, yet despite this the Council afforded no more urgency to Y’s case. When I take account also of the past disruption to Y’s education, she will feel truly let down with the lack of support she has received and the missed opportunities that go with that.
- I recognise that even if the Council had played the active role in Y’s case that it should, there may still have been disruption to Y’s education over those two academic years. The evidence of Y’s interaction with her mentors and the online tuition reports leads me to find she would struggle with the demands of a full-time curriculum. But in my view, this only made it more important the Council did what it was obliged to do in accord with Y’s EHCP. So, while recognising this factor, it provides no mitigation for the injustice caused to Y. In considering an appropriate remedy for Miss X’s injustice, I have therefore taken the view the Council should recognise Y suffered a significant loss of service over those two academic years. It should make a symbolic payment accordingly.
- Turning to the injustice caused to Y by the Council’s fault over the last academic year, I consider the loss of service more limited. This is because, as I have explained above, Y has clearly struggled to re-engage with new tutoring and mentoring services made available to her by the Council. However, considerable avoidable uncertainty and frustration has resulted from the Council’s failure to manage the EHCP review procedure in the timescales expected, and from those other service failings highlighted above.
- Over all the events covered by this complaint Miss X too has suffered injustice from the Council’s failings. She too has been let down repeatedly by the Council through its failure to communicate with her and keep to timescales around reviewing her daughter’s EHCP. Miss X will likely have experienced some distress in any event as a result of concern for how her daughter’s needs can be met. But this will have been compounded by the Council’s seeming indifference to their situation.
Agreed action
- I welcome the Council accepts the findings set out above. It has agreed a series of actions to provide a remedy for the personal injustice caused to Miss X and Y as well as to improve its service. The actions agreed take account of the Ombudsman’s published guidance on remedies Guidance on remedies - Local Government and Social Care Ombudsman.
Remedy for personal injustice
- To remedy the injustice caused to Y and Miss X the Council has agreed that within 20 working days of this decision it will:
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- provide separate apologies to both Miss X and Y. These should be in line with the guidance referred to above which sets out our expectations of councils when it comes to delivering meaningful apologies;
- if it has not already done so, issue a final amended EHCP to Miss X and Y;
- ensure that moving forward it allocates a caseworker to Y’s case who, as a minimum, will communicate with Miss X and Y at least monthly for at least the next six months, to update them on whatever steps it is taking to implement the actions set out in Y’s EHCP or to monitor its progress (this is on the assumption that Y will not have an EHCP from September 2023 that names an education setting which will be responsible for ongoing monitoring of her progress);
- make a symbolic payment to Miss X of £10,100. Of this, £8750, is to recognise a loss of service over seven terms to Y at £1250 a term taking account of Y’s age and that she has received some education provision throughout the events covered by the complaint. A further £500 for the delay in Y receiving speech and language therapy, £250 for the failure to make mentoring provision available during the spring term of 2023 and £600 for the six-month delay in issuing a final amended EHCP following the 2022 annual review. It is hoped Miss X and Y will find use for this payment that will help Y make up for her lost education;
- make a symbolic payment of an additional £500 to Miss X specifically to recognise the distress she has experienced.
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Service Improvements
- I am aware that over the past two years we have issued multiple decisions highlighting failings by the Council’s special education needs service. In May 2023 we issued a decision where the Council agreed to review its procedures for EHCPs and issue reminders to relevant staff to ensure:
- when reviewing EHC plans it does so without delay, and issues amendment notices and final amended plans within the correct statutory timescales following the review meeting;
- when re-assessing EHC needs it issues a final amended plan as soon as is practicable, and within a maximum of 14 weeks from the decision to reassess;
- it keeps families updated, responds to their queries, and follows up on any agreed actions in good time.
- Also, the Council agreed it would update us on progress with staffing in its Special Educational Needs and Disability service, including its training of new officers and clearing an email backlog within the service.
- There is no need for me therefore to restate similar recommendations in this case. However, it highlights a particular issue that arises where, as a result of the wording of an EHCP, the Council is obliged to regularly review a child or young person’s progress throughout the academic year as opposed to this responsibility resting with an education institution. This could be, as in this case, because there is an expectation a child’s provision will gradually change over time as part of a re-integration from home-based to setting-based education.
- Within three months of a decision on this complaint the Council has agreed that it will write to us and explain what action it has taken to ensure:
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- it can accurately identify all such cases;
- that all relevant staff know whose responsibility it is within its education service for ensuring the steps needed in such cases are taken;
- that it has a system in place to oversee the monitoring of such cases; so if for example the Council is under an onus to review a child’s progress once a term (outside of the annual review process) it is flagged if such a review has not taken place and that there is a procedure in place to ensure the case is prioritised for action and escalated if there is further delay.
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- The Council will provide us with evidence it has complied with the above actions.
Final decision
- For reasons set out above I uphold this complaint finding fault by the Council causing injustice to Miss X and Y. The Council accepts these findings and has agreed action that I consider will remedy that injustice and improve its service. I have therefore completed my investigation satisfied with its response.
Investigator's decision on behalf of the Ombudsman