The Ombudsman's final decision:
Summary: The Ombudsmen find fault with the way the Council conducted a child safeguarding investigation and with its failure to share information in a timely manner. The Ombudsmen also find fault with the documentation the Trust provided to inform the safeguarding process.
- The complainants, whom I shall refer to as Mr and Mrs T, are complaining about the actions of Lancashire County Council (the Council) and University Hospitals of Morecambe Bay NHS Foundation Trust (the Trust). Mr and Mrs T complain that:
- A health visitor raised a child protection alert as she had recently attended process a course on Fabricated or Induced Illness. In addition, the health visitor recorded information in the records that Mrs T had shared with her in confidence.
- A safeguarding nurse provided inaccurate information to the Child Protection Conference (CPC) and judged about the family without evidence.
- The safeguarding nurse behaved inappropriately at the CPC.
- A social worker failed to take the family’s opinions into consideration and did not listen to their views. Mr and Mrs T say the social worker showed no interest in ensuring inaccuracies in the children’s health chronologies were corrected. Mr and Mrs T say the social worker admitted she had not read them in full.
- The social worker lied to them by advising them during her first visit that there had been no multidisciplinary discussion of their case at that stage. In addition, they say the social worker was obstructive and would not provide them with contact details for the Trust’s safeguarding lead.
- The Trust and Council failed to share documentation with them in a timely manner.
- The family’s confidentiality was breached by an attendee at the CPC.
The Ombudsmen’s role and powers
- The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship
- If the Ombudsmen find evidence of fault causing injustice, they may suggest a remedy. Recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1)).
- The Ombudsmen cannot question the merits of an administrative decision or professional judgment when there is no evidence of fault in how the decision was reached.
How I considered this complaint
- In reaching this decision, I took account of the information Mrs T provided to the Ombudsmen. I made enquiries of the Trust and Council and took account of the documents and comments they provided, including the clinical records.
- I took account of relevant law, statutory guidance, and local policy.
What I found
- Section 11 of the Children Act 2004 imposes a duty on health agencies, such as the Trust, to refer a child to the local council’s children’s social care department if it has any safeguarding concerns about the child. The health agency has no authority to decide whether or a not a child is at risk of harm. Its role is simply to refer concerns to the local council with responsibility for child protection.
- Under section 47 of the Children Act 1989, councils have a duty to investigate if there is reasonable cause to suspect that a child in their area is suffering, or is likely to suffer, significant harm. The council must decide whether it should take any action to safeguard or promote the child’s welfare.
- This may involve assessing the child’s needs and the risk of harm to the child. A council may also convene a Child Protection Conference (CPC). If a council decides action is necessary to safeguard the child, it must take that action.
- Child Protection Conferences (CPCs) are multi-agency conferences that can include organisations (such as the police) over which the Ombudsmen have no jurisdiction. In the case of the CPC considered as part of this complaint, the organisations involved are within the Ombudsmen’s powers to investigate.
- If professionals are concerned that a child may be at risk of serious harm, they can place that child on a Child Protection Plan (CPP). This is a formal document intended to set out the child’s needs and those of the family. The CPP should also set out what work needs to be done to reduce the risk posed to the child, who will undertake this work and within what timeframe the work will be undertaken.
- Alternatively, if professionals are satisfied a child is not at significant risk of harm, but needs extra support, they can instead decide to place that child on a Child In Need Plan. The plan will set out the additional support the child requires and how local services will provide this.
National child safeguarding guidance
- In 2013, the Government produced guidance entitled Working together to safeguard children: A guide to inter-agency working to safeguard and promote the welfare of children (Working Together). The Working Together guidance places a shared responsibility on all agencies to work together to protect children from harm.
Local child safeguarding guidance
- Child safeguarding procedures In the Lancashire area are set out in local guidance entitled Pan Lancashire Policy and Procedures for Safeguarding Children Manual (the local safeguarding policy).
- Section 118 of the local safeguarding policy says the conference chair must ensure ‘a debate takes place which examines the findings of reports, and risk assessments and analysis is encouraged, all options are considered and the conference reaches decisions in an informed and non-discriminatory way.’
- Section 121 of the local safeguarding policy says the conference chair has the final decision as to whether a CPP is required.
- Section 122 of the policy says the chair must ‘ensure that all members of the conference are clear about the conclusions reached, the decision taken and recommendations made, and that the conference minutes accurately reflect the discussions, the decision and, where relevant, the reasons for the Conference Chair exercising his or her decision-making powers.’
Fabricated or Induced Illness guidance
- Fabricated or Induced Illness (FII) is a syndrome whereby an adult carer makes a child appear mentally or physically ill to perpetuate a relationship with health professionals. This can be done in various ways, such as fabricating or misrepresenting symptoms or manipulating test results. In some extreme cases, a carer can actually harm a child (e.g. by poisoning or physical
- FII is also sometimes known as Munchausen’s Syndrome by Proxy.
- The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.
- In 2009, NICE published guidance entitled Child Maltreatment: when to suspect maltreatment in under 18s [CG89]. This guidance lists 12 potential warning signs of FII. These include:
- Reported symptoms and signs only appear or reappear when the parent or carer is present.
- An inexplicably poor response to prescribed medication or other treatment.
- Despite a definitive clinical opinion being reached, multiple opinions from both primary and secondary care are sought and disputed by the parent or carer and the child continues to be presented for investigation and treatment with a range of signs and symptoms.
- In addition, the local Safeguarding Children Board produces guidance entitled Fabricated or Induced Illness (the FII guidance). This local guidance sets out what actions professionals should take if they suspect FII.
- Mr and Mrs T have three children. Child D was born in 2007. Child N was born in 2010. Child P was born in 2014.
- In 2014, a health visitor identified that the children had been subject to numerous medical examinations within the past few years. She queried whether there may be evidence of FII within the family.
- As a result, the health professionals involved in the children’s care met to discuss the situation on 10 September 2014. This included the health visitor, a safeguarding nurse and two paediatricians. The meeting agreed to request chronologies for the children and Mr and Mrs T from the family’s GP and the paediatric services.
- The professionals met again on 15 October 2014 to discuss the chronologies. The professionals agreed that the children had received considerable input from health services without any significant diagnoses and that Mrs T was noted to need regular reassurance about their wellbeing. The professionals concluded that FII was a possibility and agreed to refer the matter to the Council for consideration.
- On 21 October 2014, the safeguarding nurse made a referral to the Council. She recorded that the children had been subject to ‘significant numbers of hospital admissions and invasive procedures’ that had not resulted in any diagnoses. She requested that the Council consider a full FII assessment.
- The Council called a multiagency strategy meeting on 13 November 2014. The professionals present agreed to proceed with a safeguarding investigation.
- A social worker completed an assessment on 2 December 2014. She found that ‘[t]he children are all well presented and no concerns about their development, behaviour or presentation have been reported by school or other agencies aside from health.’ However, the social worker also noted that the children had experienced ‘significant medical input in their lives and even surgery.’ She noted that this could be potentially damaging to the children and recommended that ‘a child protection plan is put in place to support the family with addressing these issues.’
- The Council held the initial CPC on 3 December 2014. This included the family and professionals from local health and social care services. In addition, representatives from the police were present. Following extensive discussion, the CPC concluded that the children should be subject to a CPP ‘under the primary category of risk of emotional abuse and a secondary category of risk of physical abuse.’
- On 11 December 2014, Mrs T wrote to the Council to appeal the decision. She said the safeguarding process had been flawed. She said the documentation (including the health chronologies) considered at the meeting of 3 December 2014 contained errors.
- At a core group meeting on the same day, it was agreed the social worker would complete a full child and family assessment. This was to include an assessment of the children in school and at home. However, the meeting heard that Mrs T had declined to give professionals access to her GP records.
- The Council responded to Mrs T’s appeal on 4 February 2015. While the Council was largely satisfied with the safeguarding process, it acknowledged there had been insufficient scrutiny of the children’s health chronologies. The Council also found that it was not clear from the meeting minutes why the professionals had agreed the children should be placed on a child protection plan. As a result, the Council agreed to reconvene the CPC on 11 February 2015.
- In the meantime, the social worker completed her child and family assessment. She noted the children appeared happy and healthy. However, she expressed concern regarding the children’s extensive involvement with health services. In addition, she explained she had been unable to take significant information into account. In particular, she noted that she had been unable to view Mr and Mrs T’s clinical records or fully explore Mrs T’s mental and psychological health history. She concluded that there remained a risk of FII.
- The social worker shared her report with the other professionals, as well as with Mr and Mrs T. Mr and Mrs T restated their concern that the chronologies were inaccurate and challenged the social worker’s conclusion that the children were victims of FII.
- On 11 February 2015, the CPC reconvened. However, key health staff were absent and revised chronologies had not yet been compiled. As a result, it became necessary to adjourn the meeting until 3 March 2015.
- The CPC went ahead as planned. After extensive discussion, the meeting agreed the children would no longer be subject to the CPP process, but that the family would continue to receive informal support through local services.
- The correspondence shows that Mr and Mrs T believed the decision to place their children on CPPs was flawed and based on inaccurate information. This is reflected in their letter of 11 December 2014 in which they appealed the decision.
- The Council responded to the appeal on 4 February. The Council accepted that the two paediatricians who were present at the CPC on 4 December 2014 (as well as a teacher from the school attended by the children) felt that a Child In Need Plan would be more appropriate. Despite this, the Council said nine of the twelve professionals present agreed that a CPP was indicated.
- However, the Council said ‘we do not feel there was sufficient analysis of the chronologies in respect of the children and believe that further evaluation of the medical history is required in considering whether illness has been fabricated. Furthermore, whilst the majority of professionals agreed there was a need for a child protection plan, it isn’t always clear from the minutes what their reason was in reaching this decision.’ It was this finding that led the Council to schedule a further CPC.
- Mr and Mrs T complained again on 12 February 2015 after it became necessary to postpone the reconvened CPC. In particular, they complained it had been necessary to postpone the CPC as the corrected chronologies had not been distributed. They also reiterated their view that the decision to place the children on CPPs was wrong.
- Further to another letter of complaint from Mr and Mrs T in April 2015, the Council sent an additional response on 28 May 2015. In this letter, the Council said ‘[t]he Local Authority’s involvement with your children was triggered entirely by concerns raised by health…I understand that at the reconvened Initial Child Protection Conference, [the paediatrician’s] presence enabled a greater level of information sharing and clarification to be sought by those present in respect of the health chronologies. In turn, this enabled [the social worker]…to make a different recommendation’.
- The Council has acknowledged the CPC held in December 2014 did not appropriately scrutinise the health chronologies for Mr and Mrs T’s children. Similarly, the Council accepts that it is unclear from the minutes of the meeting why the majority of the professionals attending felt a CPP was indicated. Despite identifying these failings, the Council did not apologise to Mr and Mrs T in either of its responses. In my view, these are significant shortcomings.
- I note the Council’s view that the presence of the consultant paediatrician at the CPC on 3 March 2015 allowed the professionals present to clarify the information set out in the health chronologies. The Council said this in turn allowed the professionals to agree that CPPs were not indicated.
- However, the records of the initial CPC on 3 December 2014 show the consultant paediatrician also attended this meeting. The meeting notes clearly record his views on the clinical histories of Child D and Child N. In both cases, the consultant paediatrician emphasised that ‘the fact they had not found a cause for the symptoms did not mean there was no reason to be concerned…He did not feel the parents had any deliberate intention to harm.’ It is also of note that the other paediatrician present ‘felt that when the children had been presented it was not with unusual things for their age. She did not feel the symptoms were made up.’
- The notes of the meeting do not provide any detail around why other professionals present did not accept this view. The social worker was recorded as saying only that ‘there was a high level of concern regarding Fabricated Illness so she recommended a Child Protection Plan.’ In other cases, it was simply noted that people ‘agreed’ or ‘agreed with the Child Protection Plan’.
- The notes of the CPC of 3 March 2015 show more detailed discussion of the health chronologies. During these discussions, the consultant paediatrician again acknowledged that there had been extensive input from health services. Nevertheless, he said the children’s presenting symptoms fell within the range of normal illnesses. He said there would be ‘more concern if parents were talking about changing hospitals and consultants but that had not happened. With the small range of services involved [the consultant paediatrician] did not feel the children would be harmed in any way so did not feel that a Child Protection Plan was needed.’ Indeed, the meeting notes show he felt universal services would be able to meet the children’s needs. Those present agreed unanimously that CPPs were not indicated.
- I found no evidence to suggest the second conference had access to any significant information that was not also available to the first. The consultant paediatrician was present at both meetings and his view remained consistent throughout. On balance of probabilities, I think it likely the first conference would have reached the same conclusion if it had carried out an appropriately thorough consideration of the evidence (including the health chronologies) at that stage.
- I have no reason to doubt the professionals involved in the first CPC were acting in the children’s best interests. However, the Council did not act in accordance with the local safeguarding procedures and, in my view, cannot be said to have based its decision on a thorough consideration of the evidence. This is fault.
- This led to the children being placed on CPPs unnecessarily and caused the family considerable distress that could have been avoided. This was compounded by the fact that the reconvened CPC did not take place until 3 March 2015, three months after the original CPC.
- Mrs T complained that the health visitor raised concerns about FII on her part and that this led to the decision to initiate child protection procedures. Mrs T said she challenged errors in the health visitor’s report but the Trust and Council did not listen.
- The clinical records show the health visitor was allocated to Child N. She became concerned that both Child N and Child D were receiving extensive input from health services. She first raised her concerns with the consultant paediatrician in January 2013. The health visitor remained concerned that FII may be an issue with the family. As a result, she requested a meeting of health professionals to discuss her concerns.
- The notes of the meeting on 10 September 2014 record that the health visitor ‘had requested a meeting today to further investigate the parenting, any concerns in health and how best to support this family and safeguard the children.’
- Section 6 of the FII guidance states that ‘[a]ny Professional who has concerns that a parent may be fabricating or inducing illness in a child must discuss their concerns with their line manager and their agency’s nominated safeguarding children lead/adviser.’ The FII guidance emphasises the importance of involving other health professionals, such as the child’s GP and paediatrician.
- In this case, the health visitor discussed her concerns with health colleagues including Child N’s paediatrician, a safeguarding specialist nurse and a child protection nurse. Given the seriousness of her concerns, this was entirely appropriate and in keeping with both local and national guidance on FII. I find no fault in this respect.
- I note Mrs T’s concern that the health visitor’s report contained inaccuracies. As an example, Mrs T said the health visitor recorded that she had been assaulted by a clinician when this was not the case.
- At that stage, it was not possible for the health visitor to seek clarification from Mr and Mrs T. The FII guidance makes clear that, in cases where FII is suspected, the parents should not be involved until a multi-agency approach has been agreed.
- The records show the meeting on 10 September 2014 was only intended to be an initial discussion and all present recognised more detailed information would be needed before any further action could be taken. The consensus of the professionals involved in the children’s care was that there was sufficient concern to refer the case to the Council. This decision was agreed by several professionals and was not based solely on information from the health visitor. I do not consider any inaccuracies had a significant impact on events at this early stage, therefore.
Safeguarding Nurse - chronologies
- Mrs T complained that the safeguarding nurse presented inaccurate information to the CPC in the health chronologies and made judgements about the family without supporting evidence.
- The Trust said health chronologies had, at that time, been prepared by administrative staff and checked by a member of the safeguarding team. However, the Trust explained that all chronologies are now prepared by a healthcare professional. It acknowledged that ‘the errors made were serious and unprofessional…they significantly influenced the conference’s views of you and your family in relation to fabricated and induced illness.’ The Trust offered an unreserved apology for this.
- The Trust has acknowledged there were errors in the chronologies and this represents fault.
- It is clear the errors contributed to Mr and Mrs T’s dissatisfaction with the safeguarding process. However, I found no evidence in the notes of the CPC held on 3 December 2014 to suggest the decision to make the children subject to CPPs was based on inaccurate information in the chronologies. I consider the Trust’s apology, and the remedial action it has taken, to be a reasonable remedy, therefore.
Safeguarding nurse - attitude
- Mrs T said the safeguarding nurse’s attitude was poor when she attended the CPC. She described a number of aspects of the safeguarding nurse’s behaviour as ‘unprofessional’. This included her tendency to talk over others, ‘make faces’ and roll her eyes when she did not agree with what others were saying.
- The Trust said the chair of the CPC felt the safeguarding nurse had acted professionally. However, it acknowledged that the ‘esoteric’ terms used during discussions would have been difficult to understand and that ‘for professionals to debate in this manner with family members present would be unprofessional and upsetting.’ The Trust also said ‘the use of tutting and eye rolling by [the safeguarding nurse] would constitute intimidating and unprofessional behaviour. I am very sorry this happened.’
- The Trust confirmed that, at Mrs T’s request, it had referred her concerns about the safeguarding nurse’s attitude to the Nursing and Midwifery Council (NMC) for investigation.
- Mr and Mrs T’s complaints correspondence makes clear that they found the nurse’s behaviour upsetting. In the circumstances, I consider the Trust’s apology to be a reasonable and proportionate remedy.
Social Worker - attitude
- Mrs T complained that a social worker failed to take the family’s opinions into consideration and did not listen to their views. They said the social worker was obstructive and would not provide them with contact details for the Trust’s safeguarding lead.
- The Council said the social worker was an experienced member of staff and did not intend to appear dismissive of Mr and Mrs T’s concerns.
- The situation was clearly very distressing for Mr and Mrs T, given the nature of the allegations against them. It is also apparent from the correspondence that they found the safeguarding process frustrating. However, I have seen no persuasive evidence to suggest the social worker acted inappropriately.
- I find no fault by the Council in this respect and consider its response reasonable in the circumstances.
Social worker - chronologies
- Mr and Mrs T said the social worker failed to ensure inaccuracies in the children’s health chronologies were corrected in time for a second CPC. Mr and Mrs T said the social worker told them at a core group meeting that she had not read the chronologies.
- The Council said the chronologies were the responsibility of health colleagues rather than the social worker.
- The responsibility for providing, and correcting, the children’s chronologies lay with the Trust. The Trust acknowledged the errors Mr and Mrs T identified in the chronologies and apologised for these. It also changed its process to ensure health professionals, rather than administrative staff, now compile chronologies.
- The Council was correct to say the social worker was not responsible for making the corrections to the children’s chronologies. I consider its response in this regard to be reasonable.
- It is obviously very difficult in the absence of any further evidence to determine whether the social worker read the chronologies. I reviewed the notes of the core group meetings and was unable to find any written evidence to suggest the social worker said this.
- The evidence shows that, following the initial CPC in December 2014, the social worker completed a detailed child and family assessment. While she did not refer to specific examples in her report, she made clear that Mr and Mrs T disputed some aspects of the chronologies and that the Trust was looking into their concerns.
- With this in mind, I am satisfied the second CPC was made aware of the family’s concerns in this respect and was able to take this into account when making its decision. I find no fault on the part of the Council in relation to this issue.
Social worker – misleading information
- Mr and Mrs T complained that the social worker told them during her initial visit on 14 November 2014 that there had been no multidisciplinary discussion of their case at that stage when, in fact, there had.
- The Council denied the social worker had misled Mr and Mrs T. It said the social worker recalled having discussed the multi-agency strategy meeting with the family at her visit on 14 November 2014.
- Local guidance is clear that the Council must hold a strategy meeting where a child is at suspected risk of harm. This meeting requires representation from various health and social care agencies, as well as the police. It is a meeting of professionals and would not ordinarily include the family.
- It is not possible to establish with any certainty what was discussed at the visit on 14 November 2014. The available evidence shows both Mrs T and her step-grandmother recalled the social worker telling them there had not been a previous multiagency meeting. However, the social worker recalled having spoken to Mrs T about the strategy meeting.
- I can see no reason why the social worker would have deliberately misled the family about the strategy meeting. On balance, I consider it more likely that this was simply a misunderstanding. I find no fault in relation to this aspect of the complaint.
- Mr and Mrs T complained that the Trust and Council failed to share documentation with them in a timely manner. As an example, Mr and Mrs T said they did not receive the social worker’s initial report until the evening before the first CPC. In addition, Mr and Mrs T said they did not receive copies of the notes of the first CPC (including the children’s chronologies) until 19 January 2015.
- In its response of 4 February 2015, the Council explained that Lancashire Safeguarding Children Procedures require agencies to share reports with parents ‘at least two working days before the conference.’ The Council acknowledged this had not happened due to a problem with its computer system. However, the Council said it had offered Mr and Mrs T the opportunity to postpone the conference but they decided against this. The Council apologised for this.
- The Council’s failure to share the social worker’s report in a timely fashion was fault and the Council has acknowledged this.
- The records of the CPC of 3 December 2014 show the chair was mindful of the fact that Mr and Mrs T had not been given much time to consider the report. As well as offering an adjournment, the chair asked all professionals present to take this into account during the meeting.
- It is understandable Mr and Mrs T found this frustrating and that they were unwilling to prolong a very stressful process by adjourning the conference. The apologised for not sharing the report more promptly. In the circumstances, I consider this to be a reasonable and proportionate remedy.
- Mr and Mrs T also complained that they did not receive the notes of the first CPC for over six weeks. In my view, this delay was unreasonable, particularly given that Mr and Mrs T had not yet had an opportunity to consider the children’s chronologies. This is fault on the part of the Council.
- Mr and Mrs T complained that a day centre worker who was present at the initial CPC breached their confidentiality by sharing information about the child protection process with estranged members of their family.
- In its response of 4 February 2015, the Council ‘[a]ll agencies represented in the conference have knowledge and skills in relation to safeguarding children.’ The Council said that, had it been aware the family knew the day centre worker, this ‘would have been considered by the chairperson.’ The Council emphasised that the day centre worker attended in a professional capacity and was required to maintain the family’s confidentiality.
- In response to my enquiries, the Council explained that it had passed the matter to the day centre for investigation. The Council explained that the day centre manager met with Mr and Mrs T to discuss their allegations but was unable to identify any evidence that the worker had breached the family’s confidentiality. The Council said Mr and Mrs T would not allow the day centre manager to speak to a relative who they said would be able to verify their account.
- The evidence shows the day centre did investigate Mr and Mrs T’s allegations but was unable to find any evidence that the worker breached the family’s confidentiality.
- In the absence of any persuasive independent evidence to support the allegations, I consider the Council’s response to this issue to have been reasonable. I find no fault here, therefore.
- I find fault with the Council’s failure to carry out a thorough consideration of the evidence presented at the CPC in December 2014. In my view, this led to Mr and Mrs T’s children being placed on CPPs unnecessarily. This was not rectified until after the reconvened CPC in March 2015. This caused Mr and Mrs T considerable and avoidable distress.
- In addition, the Council did not share the minutes of the first CPC with Mr and Mrs T for over six weeks following the meeting. This is fault.
- With this in mind, the Council will, within two months of my final decision statement, write to Mr and Mrs T to:
- Apologise for the fault I have identified and acknowledge the impact this had on them and their family. The Council’s apology should acknowledge that the decision of the first CPC was flawed as it was not based upon a thorough consideration of the available evidence.
- Apologise for the delay in providing Mr and Mrs T with the minutes of the initial CPC.
- Pay Mr and Mrs T the sum of £300 in recognition of the avoidable distress they experienced as a result of the fault I identified.
- I am satisfied these recommendations constitute an appropriate remedy for the outstanding injustice in this case.
- The Council should provide the Ombudsmen with a copy of its letter to Mr and Mrs T.
- I find fault on the part of the Council in relation to the way it managed the safeguarding process in this case. This led to unnecessary distress for Mr and Mrs T. I have made recommendations to address this outstanding injustice.
- I also find fault with the Council’s failure to share information with Mr and Mrs T in a timely fashion. Again, I have made a recommendation to address this.
- I find fault on the part of the Trust in respect of the errors in the chronologies for the children and the attitude of the safeguarding nurse. However, the Trust has accepted and apologised for these failings and taken action to prevent similar problems occurring in future.
- I have now completed my investigation on the basis I have set out above.
Investigator's decision on behalf of the Ombudsman