What do complaints teach us about end of life care?

See our latest report on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.

London Borough of Harrow (25 009 666)

Category : Education > Special educational needs

Decision : Upheld

Decision date : 02 Jul 2026

The Ombudsman's final decision:

Summary: Miss X complained the Council failed to complete a key stage transfer review of her child’s Education, Health and Care Plan by the legal deadline which left them with no educational placement. We found the Council at fault for not properly carrying out a key stage transfer review and failing to act on Miss X’s concerns her child was not receiving an education. This caused Miss X and her child uncertainty. The Council has agreed to apologise and make a payment to recognise the injustice its actions caused to Miss X and her child. It has also agreed to make changes to its service to prevent the same faults happening again.

The complaint

  1. Miss X complained the Council failed to carry out a key stage transfer of her child, Y’s, Education, Health and Care (EHC) Plan when they moved from secondary to post-16 education. She also complained the review meetings did not discuss Y’s preparation for adulthood. She said this left Y without an educational placement.
  2. Miss X also complained the Council then failed to provide any interim provision while Y did not have an educational placement. She said this has negatively impacted Y’s development and wellbeing and caused distress and financial strain for the family.

Back to top

The Ombudsman’s role and powers

  1. 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)
  2. When considering complaints 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.
  3. 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)
  4. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).

Back to top

What I have and have not investigated

  1. As a publicly funded body we must be careful how we use our resources. We conduct proportionate investigations; completing them when we consider we have enough evidence to make a sound decision. This means we do not try to answer every single question a complainant may have about what the organisation did.
  2. On the broader point, we cannot always respond to complaints in the level of detail people might want. We have limited resources and must investigate complaints in a proportionate manner, focusing on general themes and issues, rather than providing a response to every individual issue raised in a complaint.
  3. I have investigated how the Council handled Y’s transition from secondary education to post-16 education, which was due to happen in September 2024. This includes looking at the steps leading up to their transition, such as the reviews of their EHC Plan.
  4. I have also investigated how the Council secured provision for Y from September 2024 onwards. I have ended my investigation in April 2025. There was a significant change in Y’s circumstances around this time, which would not be proportionate to investigate as part of this complaint.

Back to top

How I considered this complaint

  1. I considered evidence provided by Miss X and the Council as well as relevant law, policy and guidance.
  2. Miss X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

Back to top

What I found

Relevant law and guidance

Education, Health and Care Plans

  1. A child or young person with Special Educational Needs (SEN) 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.
  2. 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).
  3. There is a right of appeal to the First-tier Tribunal (Special Educational Needs and Disability) against a council’s description of a child or young person’s SEN, the special educational provision specified, the school or placement or that no school or other placement is specified in their EHC Plan. In this decision statement we refer to it as ‘the Tribunal’.

Reviews of EHC Plans

  1. Councils must arrange for the EHC Plan to be reviewed at least once a year to make sure it is up to date. The council must complete the review within 12 months of the first EHC Plan and within 12 months of any later reviews. The annual review begins with consulting the child’s parents or the young person and the educational placement. A review meeting must then take place. Following the review meeting the council must issue a decision to either amend, maintain or cease to maintain the EHC Plan. This must happen within four weeks of the meeting. (Section 20(10) Special Educational Needs and Disability Regulations 2014 and SEN Code paragraph 9.176) 
  2. Where the council proposes to amend an EHC Plan, the law says it must send the child’s parent or the young person a copy of the existing (non-amended) Plan and an accompanying notice providing details of the proposed amendments, including copies of any evidence to support the proposed changes. (Section 22(2) Special Educational Needs and Disability Regulations 2014 and SEN Code paragraph 9.194). Case law sets out this should happen within four weeks of the date of the review meeting. Case law also found councils must issue the amended final EHC Plan within a further eight weeks.

Reviews for young people moving from secondary to post-16 education

  1. For young people moving from secondary school to a post-16 institution or apprenticeship, the council must review and amend the EHC Plan – including specifying the post-16 provision and naming the institution – by 31 March in the calendar year of the transfer.  
  2. From year nine onwards, schools and colleges should start helping children and their families prepare for adulthood, including considering options for post-16 education and the skills they need for adulthood. Reviews should include this information. (SEN Code paragraph 8.21)
  3. Councils must make sure these reviews take place. (SEN Code paragraph 8.24)

The special educational needs and disability code of practice 2015

  1. The code states the underpinning principles which councils must have regard to when carrying out their functions in relation to disabled children and young people, or those with SEN. These include:
  • ensuring young people are involved in discussions and decisions about their support; and
  • providing information and time to young people to help them prepare for discussions and meetings.

What happened

  1. This section sets out the key events in this case and is not meant to be a detailed chronology.
  2. In June 2023 Miss X asked the Council for an emergency review of Y’s EHC Plan. She raised concerns about the quality of Y’s educational placement (‘the School’) and said she no longer wanted Y to continue there. Y was due to start their last year of secondary education.
  3. In July 2023 the School held a meeting to review Y’s EHC Plan.
  4. The School held a second review meeting in September 2023, once Y had returned from the summer holidays.
  5. Y was due to start their post-16 education in September 2024. In December 2023 the Council started discussing Y’s post-16 choices with Miss X.
  6. In May 2024 the Council accepted it had not found a placement for September 2024 for Y.
  7. In July 2024 the Council issued a draft amended EHC Plan for Y. It told Miss X it would continue to look for a suitable placement for Y.
  8. By September 2024 Y did not have a school or college place. Miss X started paying for different activities for Y, which she felt they needed for their learning. She spoke with the Council and asked it to provide Y with English and maths tuition. In this meeting, the Council also told her it would consider refunding her costs for Y’s activities.
  9. The Council decided to carry out a new EP assessment of Y and said it would provide them with English and maths tuition. It said it had decided it would not pay Miss X for Y’s activities because these were not in section F of Y’s EHC Plan and there was no evidence Y needed them.
  10. In December 2024 the Council carried out an EP assessment of Y.
  11. In January 2025 Miss X complained to the Council and said Y was still not receiving maths and English tuition.
  12. In February 2025 the Council agreed to refund Miss X’s costs for the activities, backdated to September 2024. It sent her details of English and maths tuition providers for her to choose from.
  13. In March 2025 the Council issued an amended final EHC Plan for Y.

Analysis

Reviewing the EHC Plan

  1. The Council told us the July and September 2023 review meetings were part of Y’s key stage transfer review. It said it arranged this review as Y was due to move to post-16 education in September 2024.
  2. The evidence shows the September 2023 review meeting was an emergency review, it was not arranged in advance by the Council. The review meeting in July 2023 was a standard annual review. Miss X asked the Council to arrange the emergency review to discuss whether Y should remain at the School for their last year of secondary education. The School’s meeting notes show that preparation for adulthood was discussed in the meeting, but not where Y wanted to go for their post-16 education in September 2024.
  3. The Council told us it believed Y wanted to continue at the School’s post-16 provision in September 2024. However, because Miss X asked to discuss if Y should remain at the School, it is clear that Miss X did not definitely want them to continue there.
  4. If the Council intended to use the July and September 2023 review meetings as review meetings for Y’s transfer to post-16, it did not make this clear to Y or Miss X in advance. This was fault. Councils must ensure they give young people information and time to prepare for meetings so they can take part in decision making about their support. The evidence shows the Council did not support Y and Miss X to explore options until December 2023, which was five months after the first review meeting.
  5. By not telling Y or Miss X the review meetings would be used as the post-16 transfer review, it denied them an opportunity to consider and explore post-16 options before the review meetings. This was an injustice to Miss X and Y. If Miss X and Y had an opportunity to prepare for the review meetings, they could have let the Council know if they wanted Y to attend a new setting for their post-16 education.
  6. The Council then did not amend Y’s EHC Plan to name which post-16 setting they would attend by the legal deadline of 31 March 2024. This was also fault.
  7. Parents and young people can appeal to the Tribunal if they disagree with the educational placement named in an EHC Plan, or if one is not named, but they only have the right to appeal against a final EHC Plan. By not issuing an amended final EHC Plan, the Council denied Miss X and Y the opportunity to appeal which educational setting Y would attend in September 2024, if needed. It also caused them uncertainty, as they did not know which setting the Council would name.
  8. I cannot say this fault left Y without an educational placement in September 2024. Miss X removed Y from the School before September 2024 as she did not feel it could meet Y’s needs. If the Council had properly carried out a key stage transfer review, I cannot say what educational placement the Council would have named. It is possible it still would have named the School, in which case the same disagreement about Y’s placement could have happened and Y still would not have had a placement in September 2024.

Preparation for adulthood

  1. The School’s records from the July 2023 and September 2023 EHC Plan review meetings show that Y’s preparation for adulthood was discussed. This included what skills they needed for future employment, health and independent living.
  2. The Code says it is the responsibility of schools and colleges to discuss preparation for adulthood with young people in reviews and it is the duty of councils to make sure these reviews take place.
  3. As the paperwork shows there were discussions around Y’s preparation for adulthood, there was no fault by the Council on this point. It had evidence the School held these discussions with Y.

Providing education

  1. The Council told us it started providing Y with educational provision from September 2024, while they did not have a school or college to attend. It said it received no concerns that Y’s provision was not in place.
  2. The evidence shows the Council accepted in September 2024 it was not arranging any education for Y. It shows Miss X paid for activities for Y from September 2024 and asked the Council to pay her back.
  3. The EP report in December 2024 said Y was still not receiving any provision, other than what Miss X was paying for, while they were out of education.
  4. The Council’s correspondence with Miss X shows it started to arrange English and maths tuition in February 2025.
  5. Therefore, it is likely, on balance, that Miss X raised concerns in September 2024 Y was not receiving any education and the Council did not start to arrange suitable education or provision for them until February 2025.
  6. Y had an EHC Plan and so, even if they weren’t attending a school, they were still entitled to the support in section F of their EHC Plan.
  7. There was no evidence the Council met its duty to provide the support that was in section F of Y’s EHC Plan. Therefore, this was fault by the Council.
  8. The Council has now paid back Miss X’s costs and so the only unremedied injustice this fault caused Miss X was uncertainty and frustration. She paid for activities for Y not knowing when the Council would start arranging provision for them, or if it would ever pay her back.

Remedy

  1. Where we find fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. When deciding remedies, we refer to our guidance on remedies.
  2. In Miss X and Y’s case, I have considered their injustice separately. An apology and a symbolic payment each for distress is appropriate to remedy their injustice. This is to recognise the frustration and uncertainty caused to them by the Council’s actions.
  3. We normally recommend a symbolic payment for distress of up to £500, but we may recommend more if we decide someone’s distress was prolonged, or if the person was vulnerable.
  4. I have considered the following when deciding an appropriate remedy to recommend for Y’s injustice:
  • that Y was at a key stage transfer;
  • that Y’s EHC Plan said they needed time to prepare for any changes so any uncertainty would have been difficult for Y to manage; and,
  • that Y continued to receive provision because Miss X arranged it.
  1. A £600 remedy payment for Y’s distress is suitable due to their vulnerability and the prolonged time they had uncertainty about their post-16 placement.

Service improvements

  1. Where we find fault by an organisation, we can recommend changes to improve how the organisation delivers its services to prevent the same issue happening to others.
  2. The Council has agreed to make the service improvements in paragraph 62 below to prevent the following faults from happening again:
  • not giving children and their parents, or young people, advice and information before key stage review meetings to enable them to take part in decision-making about the next stage of their education; and,
  • not sending out amended final EHC Plans by the legal deadlines in key stage transfer reviews.

Back to top

Action

  1. Within four weeks of our final decision, the Council will:
      1. apologise to Y and pay them £600 for the injustice caused to them by the Council delaying sending their amended final EHC Plan; and
      2. apologise to Miss X and pay her £200 for the injustice caused to her by the Council delaying arranging special educational provision for Y. The Council’s apologies should be in accordance with our guidance for making an effective apology.
  2. Within three months of our final decision, the Council will review its process for how it carries out stage transfer reviews, including how it asks schools and colleges to carry them out on its behalf. It should identify if it needs to change its process to prevent the same faults from this complaint happening again. It will send us a time-bound action plan of when it intends to make any changes.
  3. The Council should provide us with evidence it has complied with the above actions.

Back to top

Decision

  1. I find fault causing injustice. The Council has agreed actions to remedy injustice.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page

LGO logogram

Review your privacy settings

Required cookies

These cookies enable the website to function properly. You can only disable these by changing your browser preferences, but this will affect how the website performs.

View required cookies

Analytical cookies

Google Analytics cookies help us improve the performance of the website by understanding how visitors use the site.
We recommend you set these 'ON'.

View analytical cookies

In using Google Analytics, we do not collect or store personal information that could identify you (for example your name or address). We do not allow Google to use or share our analytics data. Google has developed a tool to help you opt out of Google Analytics cookies.

Privacy settings