Summary: The Ombudsmen consider Great Ormond Street Hospital (GOSH) did not withhold evidence from a child protection conference. Rather, Central Bedfordshire Council (the Council) did not share GOSH’s evidence at that conference. Also, the Council did not share the social worker’s report with Mr G before the conference in line with the safeguarding policy, which caused him frustration. The Ombudsmen consider GOSH clearly communicated its safeguarding concerns to Mr G and did not misrepresent his son’s feeding tubes coming out.

The complaint

1. Mr G complains about Central Bedfordshire Council (the Council) and Great Ormond Street Childrens Hospital (GOSH).
2. Mr G says the Council put his son, M, on a child protection plan on 2 July 2018. However, this was based on GOSH’s incomplete and inaccurate evidence about M’s feeding tubes, his weight and nutrition. Mr G says the Council should have supported M with a child in need plan.
3. Mr G says M had fewer family visits and stayed longer in hospital than needed. Also, the family suffered significant stress.
4. Mr G would like the Council to amend its records to say its decision was wrong. Mr G would like the Council and GOSH to apologise, carry out service improvements, so this does not happen to another family. He would also like the Council and GOSH to provide him with a financial remedy and/or pay for a family holiday to remedy their distress.

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The Ombudsmen’s role and powers

5. 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 (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
6. The Ombudsmen cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
7. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened.
8. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

9. I have considered the complaint information Mr G has provided to me. I have asked the Council and GOSH to comment on the complaint and provide supporting documentation. I have taken the relevant law and guidance into account. I have also written to Mr G, the Council and GOSH with my draft decision and considered their comments.
10. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).

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What I found

Key facts

11. M was born prematurely and suffers with neuro developmental delay, epilepsy and cerebral palsy.
12. Before April 2018, GOSH had concerns M’s parents were fabricating symptoms about his digestive system. In April 2018, GOSH admitted M to review his digestive system. The tests found M had a normal digestion. During the admission, GOSH made a safeguarding referral to the Council on 22 May 2018. Its concerns included:
• M’s parents admitted him to hospital for unnecessary reasons and underwent unnecessary procedures based on reported symptoms.
• M’s feeding tubes were regularly broken or dislodged
• M’s parents disengaged from his care
• M mentioned he did not want to return home
13. The Council held a strategy discussion on the same day, which included GOSH. A social worker spoke to the family and others during the safeguarding enquiry.
14. GOSH completed its medical report and chronology on 13 June 2018. Two days later, the Council called a second strategy discussion to discuss GOSH’s concerns in the medical report. The Council agreed to carry out a child protection conference (CPC).
15. The social worker completed her report for the CPC on 29 June 2018 after speaking to the family, GOSH and other professionals. The social worker shared her report with the family on 1 July (one day before the CPC). The report was not complete on 1 July as it did not include the social worker’s manager’s comments (which were added on the day of the CPC).
16. On 2 July 2018, the CPC chair decided to place M on a child protection plan.
17. In September 2018, the Council stepped M down to a child in need plan.

Analysis

18. Anyone who is concerned that a child is suffering or at risk of harm should inform the Council. Health bodies should be alert to the possibility that children may be at risk of harm and refer their concerns to the local authority for assessment.
19. Under section 47 of the Children Act 1989, councils have a duty to investigate any reasonable cause to suspect that a child in their area is suffering, or is likely to suffer, significant harm. They must decide whether they should take any action to safeguard or promote the child’s welfare. This may involve an initial assessment and a ‘core’ assessment (a more in-depth assessment). Assessments are intended, for example, to analyse a child’s needs and the risk of harm to the child. Councils may also call a CPC. CPCs are multi-agency conferences which decide whether any action is necessary to protect the child from harm.
20. The government has issued guidance to councils managing cases where there are concerns about a child’s safety or welfare. Specifically, social workers and their managers are responsible for calling and attending the CPC. They should explain the reasons for the CPC, and presenting the information gathered, including evidence of abuse or neglect and the impact on the child. They should also analyse the information to make informed decisions about how to safeguard and promote the welfare of the child (Working Together to Safeguard Children)
21. The Bedfordshire Inter-agency Child Protection Procedures detail how Central Bedfordshire should manage the safeguarding referral, the child protection enquiries and the CPC procedure. Specific to Mr G’s complaint, the procedures state it should share the social workers report for the CPC with the family at least three days before the conference.
22. Other professionals attending the conference should provide a report before the conference, outlining:
• A chronology of their involvement with the child and the family
• Their knowledge of the child’s health and development and the parent’s ability to safeguard the child
• The implications for the child’s future safety, and how to meet their needs.

GOSH was not clear what harm M suffered at home

23. I have considered GOSH’s medical report which detailed its safeguarding concerns for M, which I have listed in the ‘Key facts’ section. GOSH shared these concerns with the family and the Council before the CPC. I consider GOSH clearly explained what harm it believed M had suffered at home.

GOSH misrepresented the significance of M’s feeding tubes coming out

24. Mr G says GOSH did not clearly show how they were more responsible for M’s feeding tubes coming out than anyone else.
25. I have considered GOSH’s medical report, chronology, the social worker’s report and the CPC minutes. In both reports, GOSH and the social worker were concerned about how often M’s feeding tube dislodged while he was at home.
26. The chronology shows the high frequency of feeding tubes dislodging or broken at home and needing to be repaired. Since the age of two years old, M had 14 tube replacements at GOSH, and another 30 at another Trust.
27. GOSH accepted M’s tubes dislodged or broke in hospital and at home, and M had done this himself at times. GOSH said this was happening too often and could not explain the high frequency. GOSH said this caused M harm by the radiation used at having to replace them. Therefore, I do not consider GOSH misrepresented the importance of M’s tubes breaking or dislodging.
28. There were discrepancies between GOSH and the social worker about the exact amount of times tubes had dislodged at home, requiring a replacement. However, this did not take away from their concerns about the high frequency of M’s feeding tubes coming out.

The Council unfairly placed M on a child protection plan while GOSH withheld key information from the conference

29. I have considered if the Council followed the local safeguarding policy in how it decided to place M on a child protection plan.
30. I have considered GOSH’s medical report, growth charts and the chronology. Those reports included information about M’s weight and nutrition. The medical report, chronology and growth charts are robust and place M’s health in the context of its safeguarding referral. GOSH sent that information to the Council and family before the CPC. This was in line with the local safeguarding policy.
31. The Council did not share GOSH’s documents at the CPC. This was not in line the national guidance. The Council, GOSH and the family understood the contents of those documents. The social worker robustly addressed GOSH’s concerns in her report for the CPC. Also, the social worker carried out a detailed analysis of GOSH’s concerns. However, the Council still missed the opportunity to share GOSH’s documents with the CPC to consider before making their decision. This meant not all professionals at the CPC had a full picture of M’s health – including his weight and nutrition. That was fault.
32. I have considered how the omitted GOSH evidence from the CPC would have impacted the decision to place M on a child protection plan. I do not agree, on the balance of probabilities, this would have changed the CPC’s decision. Therefore, the fault did not cause an injustice to Mr G and his partner. However, the Council needs to ensure similar fault does not happen to others.
33. I consider the Council should have provided the social worker’s report to the family sooner than the day before the CPC. This was fault and not in line with the local safeguarding policy. The Council completed the report on the day of the CPC. The delay providing the family with the social worker’s report limited the time the family had to review the information before the CPC. This was a missed opportunity. I recognise the frustration this would have caused Mr G and his partner. The Council need to remedy the injustice Mr G and his partner suffered.

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Recommendations

34. Within four weeks, the Council should apologise to Mr G and his partner for the frustration caused by giving them one day to review the social worker’s report before the CPC.
35. Within eight weeks, the Council should ensure staff are aware of their duties under the local safeguarding policy. Specifically, the Council should complete and provide the social worker’s report at least three days before the CPC. Also, Council staff should share important information received from professionals with all people attending CPCs.

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Final decision

36. I consider GOSH detailed their safeguarding concerns to the family in a medical report and chronology which they provided before the CPC. Also, I do not agree GOSH misrepresented the frequency of M’s feeding tubes breaking or dislodging.
37. The Council should have shared the social worker’s report with the family at least three days before the CPC. It did not do this which was fault, which caused Mr G and his partner frustration. Also, the Council should have shared GOSH’s medical report, chronology and growth charts with attendees at the CPC. This was fault. However, on the balance of probabilities, I do not consider it would have changed the outcome of the CPC.

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Investigator's decision on behalf of the Ombudsman