Summary: Ms X complained that Sheffield City Council and Sheffield Children’s NHS Foundation Trust failed to address the impact of their failings during a child safeguarding enquiry. We are satisfied the Council and the Trust have now proposed appropriate and proportionate action to resolve the complaint. Because of this, we will not investigate Ms X’s complaint.

The complaint

1. In the summer of 2023 Ms X took her baby daughter to a scheduled appointment at Sheffield Children's Hospital, part of Sheffield Children’s NHS Foundation Trust (the Trust).
2. Ms X complains that hospital staff responded unreasonably and disproportionately to a small bruise on her young daughter’s face. Specifically, Ms X complains the hospital made a safeguarding referral to Sheffield City Council (the Council) despite their being inadequate evidence to warrant one. Ms X also complained about the way the Council managed the safeguarding process, and about a lack of support from the Council and the Trust throughout it.
3. In addition, Ms X complained that:

• the Council and the Trust failed to provide a joint response to her complaint; and,
• there were unreasonable delays in the Trust responding to her complaints.

4. Ms X said she and her partner and their daughter were “imprisoned” in the hospital for 30 hours. She said that professionals made her and her partner feel they had been abusive to their children and said social workers threatened them. Ms X said that since these events she had suffered panic attacks, bouts of uncontrollable crying and severe anxiety. She said she had needed to see her GP about this and was still receiving treatment. Ms X said these events had affected her that much that she no longer left the house with her children, and never with them both at once unless she had someone else with her.
5. Further, Ms X said she and her partner had to have time off work after the events. Ms X said this was because she did not dare to have the children on her own as she was scared that one of them could be harmed in an accident. Ms X said she did not even want to leave them in a room together for fear of something like this happening again. Ms X said she had lost out on spending “proper time” as a family while she was on maternity leave. She said this time had been completely tainted. Ms X also said she had lost friends because she did not dare tell anyone what had happened.

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The Ombudsmen’s role and powers

6. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
7. If we are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, we can complete our consideration and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i))

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How I considered this complaint

8. I considered evidence provided by Ms X, the Council and the Trust as well as relevant law, policy and guidance. I spoke to Ms X on the phone and exchanged written correspondence with the Council and the Trust.
9. Ms X had an opportunity to comment on my draft decision.

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What I found

10. In the summer of 2023 Ms X took her young baby, Z, to a planned appointment at Sheffield Children's Hospital. Z was at an age when she was not yet crawling or rolling over. Z had a bruise on her face and Ms X and her partner did not know where it had come from. Hospital staff referred Z to the Council which decided to make safeguarding enquiries. Professionals said Z had to stay in hospital overnight. Ms X and her partner stayed on the ward with her. Council staff also asked Ms X’s parents to bring Z’s older brother into the hospital the next day for examination. Ms X and her family returned home following the examination of Z’s brother.

Complaints to the Council and the Trust

11. Ms X complained about what happened. The Council and the Trust investigated her complaints separately. At several points, the responses referred her to the other organisation. With the complaint to the Trust, Ms X received written responses:

• 70 working days after she made her first complaint;
• 119 working days after she confirmed her outstanding concerns, after a local resolution meeting; and,
• 78 working days after she made a final follow-up complaint.

12. The Council and the Trust identified failings in the way they treated Ms X during this time. Specifically, the Council accepted that:

• a social worker should have visited Ms X in person on the day it received the Trust’s referral, but this did not happen. Further, it said the decision to communicate solely by telephone lacked empathy and understanding of the impact on Ms X and her partner;
• there may have been times where its communication did not support Ms X to fully understand the safeguarding process or the reasons for the Council’s decisions. The Council said it meant there had been a missed opportunity to answer many of the questions Ms X had;
• its first response to the complaint had not:
• shown any understanding of the impact of poor or inconsistent communication from social care and hospital staff, or
• recognised there was no evidence to show there had been any attempts to support Ms X and manage her expectations and anxieties;
• it should have arranged a multi-agency strategy meeting on the day it received the Trust’s referral, but did not do so;
• the arrangements for Ms X’s daughter’s admission to a hospital ward were inadequate. It said the case had “identified a disconnect” in the safeguarding process when staff decide to admit a child to ensure they are kept safe until medical investigations are complete;
• a social worker should have attended the child protection medical with Ms X’s son but did not;
• there should have been a hospital discharge meeting but this did not take place; and,
• a social care assessment lacked detail and a thorough analysis, and there was a lack of evidence to show why the it closed the case quickly. The Council apologised that it did not clearly explain the reasons for closing the case to Ms X at the time.

13. The Council said it had commissioned the Children’s Services’ principal social worker to put together a training package (in the form of a workshop) to present to hospital staff of all levels. It said it would video it to enable regular delivery of the training.
14. In its responses the Trust accepted that:

• its staff may not have clearly and sensitively explained the safeguarding process to Ms X when they decided to refer Z to the Council;
• there was a gap in the support provided to Ms X and her partner, as parents. It said staff did not give enough information to her when she was on the ward about food and facilities available to them; and,
• sensitive conversations inappropriately took place in public areas.

15. The Trust also said:

• it had had meetings with the Council to review Ms X’s complaint and look at what steps they could put in place to address the concerns she had raised;
• there was a joint project, which was ongoing (at the time of writing in May 2024), which aimed to improve information and learning for staff about the process and how to support families; and,
• it accepted that a joint response with the Council would have been a better approach, and that it had agreed to follow this process with the Council for future complaints.

Initial analysis

16. The claimed injustice is very significant, as detailed in paragraphs 4 and 5.
17. I do not consider there is a realistic prospect that an investigation would find fault with the Trust’s decision to make a child protection referral. Also, an investigation is not likely to find fault with the Council’s decision to start s47 enquiries and to put a safety plan in place. From the papers I have seen to date, these decisions appear to have been made in good conscience, and in line with applicable guidelines, aimed at ensuring a young infant was not at risk of harm.
18. The Trust and the Council have accepted failings in the way they communicated with Ms X. An investigation seems more likely than not to find that, with more effective communication, Ms X’s distress may have been lessened. However, it seems equally likely to find that better communication would not have completely removed Ms X’s upset and stress with the situation.
19. Because of this, it is unlikely that an investigation would find an injustice of the scale and significance Ms X complains of. Specifically, it is highly unlikely an investigation by the Ombudsmen would find that fault by the Trust and the Council led directly and avoidably to Ms X’s diagnosis of PTSD. It seems more probable that an investigation would say that failings in communication meant there was a lost opportunity to lessen Ms X’s distress.

My contact with the Council and the Trust

20. Following this early analysis, I contacted the Council and the Trust. I explained that, if the case continued to an investigation, our work would focus on whether they had done enough to consider and address the impact their faults had on Ms X and her partner. I also noted that an investigation would be likely to find fault that they did not conduct a joint investigation, and that there were avoidable delays by the Trust. And, I asked for an update on the work they had done to help prevent recurrences.

The Council

21. The Council:

• acknowledged the apologies it offered could have been more meaningful had they issued a joint letter of apology with the Trust;
• the wording of its apologies could have been better developed to include more recognition of the impact on Ms X and her partner in terms of the avoidable distress the failings caused them;
• agreed it would be appropriate to offer Ms X and her partner a symbolic remedy payment for the avoidable distress caused by the substantive failings; and,
• accepted that Ms X was put to additional time and trouble in pursuing matters via two separate complaints processes. The Council acknowledged it would be appropriate to apologise for this and offer a symbolic payment to recognise the impact.

22. In terms of learning from the complaint and improving its service, the Council said it had:

• discussed the timeliness of strategy meetings at a worksite meeting. It said the same issues would be raised bi-annually at future worksite meetings to ensure all staff were mindful of issues around the timing of strategy meetings and potential impact on parents;
• participated in a meeting with the Trust in May 2024 to discuss a proposal to deliver some training to ward staff within Sheffield Children’s Hospital. It said staff agreed an information factsheet would be better. They felt this would ensure as many staff as possible received the information and that it could be accessed again in the future as needed; and,
• developed a factsheet to support staff responding to safeguarding investigations and shared this with the Trust in October 2024.

23. In addition, the Council said it would ask its complaints manager to review its protocols for joint complaint handling. It said it would ask the manager to ensure the future opportunities for joint handling were not missed.
24. Overall, the Council said it would welcome the opportunity to develop and issue a further letter of apology to Ms X. It said this would fully recognise the impact its failings had on Ms X and her partner in terms of the avoidable distress they were caused. And, it said it would recognise the additional time and trouble they experienced pursuing matters via two separate complaints processes. The Council said it would be happy to liaise with the Trust to send a joint apology, if Ms X would prefer it. It said it would also offer of a payment of £500 to recognise the impact of its failings.

The Trust

25. The Trust:

• accepted that it had not fully recognised the impact its substantive failings had on Ms X;
• acknowledged that it should have considered the complaint jointly with the Council. It said the failure to do so was an error on its part; and,
• accepted that it had not responded to Ms X’s complaint quickly enough and did not provide timely updates.

26. In terms of service improvements, the Trust said it had:

• circulated the Council’s factsheet to its wards to be shared with ward staff;
• started the process of updating the ‘safeguarding’ page on its intranet and would include the factsheet as a resource available for staff;
• reiterated to its Complaints Team the arrangements that are in place for joint complaint handling; and,
• introduced a new system for handling complaints which included a Governance Team. The Trust said they would ensure the appropriate staff were involved in complaint investigations and would highlight and escalate any delays.

27. Overall, the Trust said it was willing to provide a fresh apology to Ms X to acknowledge the impact its failings had on her. It said it would also offer Ms X £500 to act as an acknowledgement of the impact its failings had. The Trust said it would also produce an action plan to address and monitor the failings in this case.

Further analysis

28. The remedies the Council and Trust have proposed are appropriate and proportionate to the injustice an investigation would be likely to find. In addition, they both appear to have taken appropriate steps to help improve services and avoid recurrences. An investigation by the Ombudsmen is unlikely to recommend anything more or different, even if we were to uphold the complaint. I have, therefore, closed this case on the basis that, during our consideration of the case, the Council and the Trust have identified actions which will satisfactorily resolve the complaint.

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Decision

29. We have upheld this complaint and closed it because the Council and the Trust have agreed to resolve the complaint early by providing a proportionate remedy for the injustice caused to Ms X. They have also taken appropriate steps to improve their service for others.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman