Summary: The Council was at fault. It did not secure Ms X’s child, Y’s, speech and language therapy (SALT) or occupational therapy (OT), had poor record keeping practices and communicated poorly with Ms X. This caused Ms X frustration and meant Y missed provision to which they were entitled. The Council will apologise to Y, make a symbolic payment to Ms X, review the impact of Y’s lost SALT and OT, consider how it can communicate with Ms X in the future and put in place service improvements.

The complaint

1. Ms X complained the Council failed to secure the delivery of occupational therapy (OT) and speech and language therapy (SALT) provision set out in her child, Y’s, Education, Health and Care (EHC) Plan. She said her concerns were raised in Y’s annual reviews, but SALT and OT were still not secured. Ms X also complained about poor Council record keeping and poor Council communication. Ms X said as a result, Y missed out on SALT and OT provision to which they were entitled which also caused them mental health issues and it caused her distress and time and trouble chasing the Council.

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The Ombudsman’s role and powers

2. 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)
3. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
4. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
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(1), as amended)
6. 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

7. As explained in paragraph three above we cannot investigate late complaints unless we decide there are good reasons. Ms X complained to the Ombudsman in late March 2025 about events starting in 2016. Part of the complaint is therefore late and there are no good reasons to exercise discretion to investigate events going back to 2016.
8. I have investigated between late March 2024, 12 months before Ms X complained to us and mid-March 2025 when the Council issued its stage two response.

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How I considered this complaint

9. I considered evidence provided by the Council and Ms X and I spoke to her on the telephone as well as considering relevant law, policy and guidance and our guidance on remedies published on our website.
10. Ms X and the Council had an opportunity to comment on my draft decision. I considered comments received before making a final decision.

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What I found

Relevant law and guidance

11. A child or young person with special educational needs may have an Education, Health and Care (EHC) Plan. This document sets out the child’s needs and what arrangements should be made to meet them. The EHC Plan is set out in sections. We cannot direct changes to the sections about their needs, education, or the name of the educational placement. Only the tribunal or the council can do this. Section F sets out the educational provision needed by the child or young person and Section I sets out the name and/or type of school.

Maintaining the EHC Plan

12. The Council has a duty to make sure the child or young person receives the special educational provision set out in Section F of an EHC Plan (Section 42 Children and Families Act). The Courts have said the duty to arrange this provision is owed personally to the child and is non-delegable. This means if the council asks another organisation to make the provision and that organisation fails to do so, the council remains liable (R v London Borough of Harrow ex parte M [1997] ELR 62), R v North Tyneside Borough Council [2010] EWCA Civ 135).
13. We accept it is not practical for councils to keep a ‘watching brief’ on whether schools and others are providing all the special educational provision in Section F for every pupil with an EHC Plan. We consider councils should be able to demonstrate appropriate oversight in gathering information to fulfil its legal duty. At a minimum we expect it to have systems in place to:
• check the special educational provision is in place when a new or amended EHC Plan is issued or there is a change in educational placement;
• check the provision at least annually during the EHC review process; and
• quickly investigate and act on complaints or concerns raised that the provision is not in place at any time.

What happened

14. Y has special educational needs including Autistic Spectrum Disorder (ASD), attention deficit hyperactivity disorder (ADHD), social, emotional and mental health needs.

Background

15. Y’s latest Education, Health and Care (EHC) Plan was issued in early 2021 and Section I named a mainstream secondary school, School 1, from September 2021. The key parts of Section F in this Plan included the requirement for Y to receive:
• Speech and Language Therapy (SALT) for 17 hours per academic year, comprised of biannual reviews, seven therapy sessions over the academic year and four hours liaison and training. The delivery of the SALT provision was to be provided by a speech and language therapist, school staff and family members. It said the combination of direct and indirect work would be reviewed on a yearly basis to meet Y’s needs; and
• three occupational therapy (OT) visits per annum (one visit per term) to include one to one reviews, goals and programme updates if necessary and any changes would be discussed with School 1 and Ms X. The OT would also contribute to Y’s annual reviews on a yearly basis.
16. Ms X raised concerns with the Council about Y not receiving their SALT and OT provision for many years. Evidence shows in late 2022 the Council told Ms X, Y’s school was exploring therapy options for Y which the Council would fund.
17. In mid-January 2024 School 1 held Y’s annual review. In this meeting Ms X raised concerns again that Y had not received the SALT or OT provision required by their Plan.

Mid-March 2024 onwards

18. Between mid-March 2024 and mid-January 2025 Y did not receive their SALT or OT provision.
19. In early January 2025 a specialist advisor for ASD and ADHD wrote a report about Y. The report noted Y’s mental health had declined since September 2024 and there were ongoing concerns about Y’s emotional wellbeing. Additional needs were identified for Y around emotional regulation and communication and the need for consistent support from a SALT and Children and Adolescent Mental Health Services (CAMHS).
20. In mid-January 2025 School 1 held Y’s latest annual review and it recommended Y’s Section F provision was amended. The review record noted Y was impacted by their lack of SALT and OT provision which was leading to increased school absences and mental health concerns. It said SALT and OT were crucial for Y. The actions included arranging discussions with Ms X and the School about OT and getting quotes for in person SALT for Y.
21. In mid-January 2025 a Council email said there had been a historic confusion with saving documents and Y’s previous SALT report was sent to a previous case worker but it had not been saved on their pupil file. The email said the Council was contacting SALT and OT providers for Y.
22. In late January 2025 Ms X made a formal complaint to the Council. She said Y had not received their SALT and OT provision which was raised in Y’s annual reviews, and it should be put in place immediately. Ms X said Council commissioned additional assessments to identify Y’s support needs could not be located by the Council and there was poor record keeping. She said there had been a breakdown in communication between her and the Council and the Council did not return her calls. She said the Council had provided false information about staff leaving the Council.
23. In late February 2025 the Council responded to Ms X’s complaint and said it:
• should have ensured Y’s therapy provision was in place;
• acknowledged Ms X’s concerns about Y’s lack of SALT and OT were raised in 2022 and in Y’s annual reviews and Y’s school was sourcing the therapy support but this was not followed up by the Council. It apologised for the frequent staffing changes and poor oversight of Y’s case. It said SALT and OT had been sourced by the Council and the arrangements had been confirmed with Ms X and School 1;
• apologised it could not locate Y’s commissioned therapy reports. It said there was a significant turnover of staff and it was likely the case officer at the time did not save the reports on Y’s pupil record. It said it had been addressing the issue by increasing recruitment of permanent staff members but continued to rely on interim staff;
• was sorry Ms X’s communication with the special educational needs (SEN) team was unsuccessful and her calls had not been returned. It said it had implemented a customer standard that all communication must be responded to within five working days;
• there was a high turnover of case officers but its SEN management team remained as permanent members of staff and it was sorry Ms X had been misinformed that managers had left;
• was sorry it had not kept better oversight of Y’s case and Y had not received the therapy provision in their EHC Plan. It said it had moved to secure SALT and OT arranging them to meet Y in the Summer term. It said on receiving advice would implement any EHC Plan changes needed and it had spoken to School 1 to ensure funding was in place;
• confirmed fortnightly oversight until Y’s therapy provisions were in place and
• had improved its commissioning arrangements.
24. The same day Ms X contacted the Council and said the stage one complaint response had not fully addressed her concerns and she escalated her complaint to stage two of the Council’s complaints procedure.
25. In mid-March 2025 the Council issued its stage two response to Ms X. It said each point raised at stage one had been investigated and an apology was provided where failings were identified. It apologised again for the lack of therapy provision, inconsistency in communications, the impact of staff absences which led to weak oversight of Y’s case. It said the Council was working to secure Y’s OT and SALT provision and Y’s EHC Plan would be amended in line with advice. It upheld Ms X’s complaint and gave the Ombudsman’s details if she remained unhappy.
26. Ms X remained unhappy and complained to us.

Enquiries

27. When I spoke to Ms X on the telephone she told me she continued to have concerns around Y’s SALT and OT provision, Y’s EHC Plan had not been amended and the Council continued to communicate poorly with her and had tried to block her emails.
28. Evidence from a Council email sent to Ms X in July 2025 confirmed the Council had put in place SALT and OT for Y in Spring 2025 and it was still available to Y. Ms X told me Y was struggling to engage with the new SALT and OT provision. Ms X can raise ongoing concerns through a new complaint to the Council.

My findings

SALT and OT provision

29. The Council accepted Y did not receive the SALT and OT provision set out in their EHC Plan and it said it should have been in place. This was fault that meant Y missed provision to which they were entitled. The Council has already apologised to Ms X for not keeping better oversight on Y’s provision due to frequent staff changes. It said it would carry out fortnightly oversight until Y’s SALT and OT provision was secured and it would improve its commissioning arrangements. Given Y did not receive any SALT or OT provision in the investigation period it is considered the remedy offered by the Council was not enough. The Council has agreed to the additional actions below.

Record Keeping

30. The Council accepted it could not locate Y’s commissioned therapy reports. It said there was a significant turnover of staff and it was likely the case officer at the time did not save the reports on Y’s pupil record. This poor record keeping was fault and caused Ms X frustration. The Council apologised and said it had been addressing the issue by increasing recruitment of permanent staff members. The apology remedied Ms X’s injustice. The Council will provide evidence of the staff recruitment, and the Council has agreed to the additional service improvement in the actions section below.

Communication

31. The Council accepted it had communicated poorly with Ms X by not always returning her calls and giving incorrect information about staff leaving the Council. The Council’s poor communication was fault and caused Ms X frustration. Communication between Ms X and the Council continues to be strained. The Council has already apologised to Ms X which partly remedied the injustice caused. It will provide evidence it has put in place its customer standard so all communication is responded to within five working days, as explained in the Council’s stage one response. Due to ongoing communication issues the Council will also consider how Ms X and the Council can improve communication moving forward.

Service Improvements

32. The Ombudsman has already made service improvement recommendations to this Council on a similar case. As a result of an earlier complaint to us, the Council has agreed to:
• ensure its staff are clear about its non-delegable duty to ensure EHC Plan provision is in place;
• check EHC Plan provision is in place when it issues a new or substantially different EHC Plan, and properly investigate complaints or concerns that provision is not in place at any time;
• ensure arrangements are clear for how support from therapy services will be provided where it maintains an EHC Plan for a child that attends a school in a different council’s area; and
• ensure effective case management of EHC Plans when staff leave and are replaced, so statutory timescales are met and issues responded to in good time.
33. No further service improvements on these issues were needed.

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Action

34. Within one month of the final decision the Council will:
1. apologise to Y to acknowledge the impact of their lost SALT and OT provision between late March 2024 and mid-March 2025;
2. pay Ms X a symbolic payment of £600 to acknowledge the impact of Y’s lost SALT and OT provision between late March 2024 and mid-March 2025. This remedy was calculated at £200 per term, in line with the Council’s guidance on remedies;
3. review the impact of Y’s lost SALT and OT provision to address the shortfalls so Y is close to where they would have been had the lost provision not occurred;
4. consider how it can communicate with Ms X in the future about Y’s education. This might take the form of a communication plan;
5. remind relevant staff of the need for accurate record keeping ensuring relevant documents are saved to pupils files; and
6. provide evidence the Council has put in place the service improvements set out in paragraph 23 above.
35. The Council will provide us with evidence it has complied with the above actions.

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Decision

36. I have completed my investigation finding fault causing injustice. The Council has agreed to take action to remedy the injustice caused and prevent recurrence of the faults.

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Investigator's decision on behalf of the Ombudsman