The Ombudsman's final decision
Summary: Ms X complained about the way the Council assessed her family situation. There was no fault in the way the Council considered Ms X’s complaint about this matter.
The complaint
Ms X complains about the way the Council dealt with her and her children, she says, the Council: failed to understand and support the needs of her disabled son; assessed her home and family unfairly by failing to acknowledge her son’s additional needs; and wrongly held a strategy meeting and started section 47 enquiries which wrongly led to a child protection plan.
Ms X says this has caused her significant distress because the Council judged her without understanding her family circumstances and her son’s disabilities.
The Ombudsman’s role and powers
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) The law says we cannot normally investigate a complaint unless we are satisfied the organisation knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the organisation of the complaint and give it an opportunity to investigate and reply. (Local Government Act 1974, section 26(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) Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).
What I have and have not investigated The start date of my investigation is October 2024. I have not investigated any matters that happened after October 2025, because this is when Ms X complained to us.
I have not investigated Ms X’s complaint that the Council wrongly held a strategy meeting and started section 47 enquiries. This is because, there is no evidence that Ms X complained about this matter to the Council before she complained to the Ombudsman. We generally expect complainants to use a council’s complaints procedure before we will investigate a complaint.
In this case, if Ms X was unhappy with the Council’s actions in relation to the strategy meeting and any section 47 enquiries, it would have been reasonable for the Council to have had a chance to investigate and respond to her concerns.
I have also not investigated Ms X’s substantive complaints. I have explained my reasons for this in paragraph 59.
I have investigated the Council’s actions in response to Ms X’s complaint.
How I considered this complaint
I considered evidence provided by Ms X and the Council as well as relevant law, policy and guidance.
Ms X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.
What I found
Legislation and guidance Section 17 duties Section 17 of the Children Act 1989 says councils must safeguard and promote the welfare of children within their area who are in need.
A child is in need if: they are unlikely to achieve or maintain a reasonable standard of health or development unless the council provides support; their health or development is likely to be significantly impaired unless the council provides support; or they are disabled.
Duty to Investigate 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. They must decide whether they should take any action to safeguard or promote the child’s welfare. (Children Act 1989, section 47) The council should make initial enquiries of agencies involved with the child and family, for example, health visitor, GP, schools and nurseries. The information gathering at this stage enables the council to assess the nature and level of any harm the child may be facing. The assessment may result in: no further action; a decision to carry out a more detailed assessment of the child’s needs; or a decision to convene a strategy meeting.
Section 47 of the Act places a duty on agencies, but mainly the council and the police, to make “such enquiries as they consider necessary to enable them to decide whether to take action to safeguard or promote the welfare of a child in their area”.
If the information gathered under section 47 supports concerns and the child may remain at risk of significant harm the social worker will arrange an initial child protection conference (ICPC). The ICPC decides what action is needed to safeguard the child. This might include making the child a ‘child in need’ (CiN) and implementing a safety plan.
Child Protection Conference (CPC) arrangements If, following a referral and an assessment by a social worker, a multi-agency strategy meeting decides the concerns are substantiated and the child is likely to suffer significant harm, the council convenes a Child Protection Conference.
The Child Protection Conference decides what action is needed to safeguard the child. This may include a recommendation that the child should be supported by a Child Protection Plan.
After the Initial Child Protection Conference (ICPC), there will be one or more Review Child Protection Conferences to consider progress on action taken to safeguard the child and whether the Child Protection Plan should be maintained, amended, or discontinued.
Review Child Protection Conferences should be held within three months of the initial conference, and thereafter at maximum intervals of six months.
The Child Protection Conference is a multi-agency body and is not in itself a body in the Ombudsman's jurisdiction.
The Child Protection Conference plays an advisory role. But the final decision, for example whether to place a child on a Child Protection Plan or to discontinue a Plan, is the responsibility of the council. We would generally consider it appropriate for a council to follow the recommendations of the Child Protection Conference unless there was good reason not to.
The London Safeguarding Children Procedures The Council has signed up to the London safeguarding children procedures.
This notes that the chair of a child protection conference will be a local authority children's social care manager or an independent chair, who is accountable to the Director of Children's Services. They must not have or have had operational or line management responsibility for the case. Wherever possible, the same person should also chair subsequent child protection reviews in respect of a specific child.
The procedures also explain a nationally set threshold for significant harm: Has the child suffered significant harm? and Is the child likely to suffer significant harm in the future?
The test for likelihood of suffering harm in the future should be that either: The child can be shown to have suffered maltreatment or impairment of health or development as a result of neglect or physical, emotional or sexual abuse, and professional judgement is that further ill-treatment or impairment is likely; or A professional judgement, substantiated by the findings of enquiries in this individual case or by research evidence, predicts that the child is likely to suffer maltreatment or the impairment of health and development as a result of neglect or physical, emotional or sexual abuse.
These procedures also explain that due to the nature of the information that may be contained within the police report (e.g. the disclosure of confidential information about a third party), the police report will only be shared with the conference chair who will summarise the relevant information in the meeting or ask the police representative to do so.
Complaints about child protection conferences The London Safeguarding Children Procedures also sets out the process for dealing with complaints about child protection conferences. This includes: The decision to make the child the subject of a child protection plan may be challenged if: That the criteria for the decision that the child should have a Child Protection Plan were not met; That the criteria for the decision that the child should continue to have a Child Protection Plan were not met; That the criteria for the decision that the Child Protection Plan should be discontinued were not met; and/or That the information on which the conference decision was based proved substantially incorrect.
Stage one is the informal response to a complaint made about the child protection process. This involves the responsible child protection conference service and child protection conference chair.
Stage two is the formal stage of the process. This will involve the manager responsible for the child protection conference service and/or a senior manager for children's safeguarding. A complaint meeting will consider: Minutes of the Child Protection Conference; Reports to the Child Protection Conference; Correspondence re complaint at Stage 1.
The meeting should still aim to address areas of dissatisfaction and to resolve matters. Following the meeting the complainant should receive a letter to confirm what was agreed and to advise the complainant of their right to move to Stage 3, if they are still dissatisfied.
Stage three is an appeal panel. The chair of the panel will be a senior manager from the safeguarding children partner agencies. The Panel will be an interagency panel made up of at least two senior representatives from Safeguarding Children Partnership agencies, none of whom have previous or present direct line management responsibility for the case in question.
The panel will consist of the Panel Chair and at least two members of Safeguarding Children Partnership agencies. To communicate any specific concerns and recommendations relating to practice or procedure on the part of any agency or organisation to the relevant senior manager.
The Panel may make one or more of the following decisions based on a majority view: That Child Protection Conference procedures were followed correctly; That Child Protection Conference procedures were not followed correctly and recommend how to remedy this; To support the original Child Protection Conference decision; Recommend Child Protection Conference is reconvened with the same or different conference chair, to reconsider a recommendation regarding decision that the child should be or continue to be, subject to a Child Protection Plan and the category of Significant Harm on which such decision is based; To decide they have insufficient information to make a decision and set out a timescale for completing the task and set a date for a further panel; To decide whether there are any learning points for a specific agency; What happened?
I have summarised below some key events leading to Ms X’s complaint. This is not intended to be a detailed account of what took place.
Ms X and her family were being supported by the Council under child in need processes.
In early January 2025, the Council told Ms X that it would be holding a strategy meeting because of concerns it had about her and her children.
The Council held this meeting the following week and representatives from the Council, police, education and health services attended. The Council and the other agencies all agreed that the Council would complete a section 47 investigation. It also decided it would progress to an ICPC.
The ICPC was held in early February. Ms X and representatives from the children’s school, the Council, education, police, children’s mental health services, and health attended.
All representatives that were asked to give a view said the children should be subject a child protection plan. The chair agreed with this unanimous view and decided the children should be subject to a child protection plan under the category of emotional abuse.
Ms X complained to the Council in mid-February that: Police shared information with the Council before the conference which the Council failed to share with her before the ICPC.
The Council’s approach at the ICPC was unfair and it used parental blame to cover up agencies’ mistakes and failure to fulfil their responsibilities.
The conference failed to adequately explore appropriate alternative support for the family that could have addressed the identified concerns without the need for a child protection plan.
The Council responded to her complaint at the end of February, noting it had involved the responsible child protection conference service and child protection chair in its investigation. It noted: all agencies working with the family should provide a report for conference and share this with the family before conference, apart from the police, when the chair can instead summarise confidential information for the family. The Council did not uphold her complaint that it failed to share this with her; it did not uphold Ms X’s complaint that the child protection plan was unfair and instead focused on parental blame. It noted the role of the conference chair was to analyse the information shared in the conference and they are independent of the social work teams; and it also noted that the decision to place the children on a child protection plan was based on the threshold for significant harm being met. It explained the ICPC was not to consider alternative support, it was to consider whether there was enough evidence to satisfy that the children were experiencing significant harm. The view of representatives at the meeting were unanimous that the threshold for a child protection plan had been met.
Ms X disagreed with the Council’s complaint response and escalated her complaint to stage two in March.
The Council held a review CPC at the end of April. Ms X attended the meeting along with representatives from the Council, education and health services. All but one representative considered the child protection plan should remain. The chair agreed with this view.
In early May, the Council arranged a meeting between Ms X, two senior managers within the reviewing service and a senior safeguarding manager to discuss her complaint at stage two. It then wrote to her a few weeks later with its stage two response. It decided: It did not uphold Ms X’s complaint that the Council failed to share police information with her before the ICPC, noting that procedures highlighted that sensitive police information would only be shared with the conference chair who would then summarise it in the meeting.
The child protection conference followed the correct process. The attendees and the Council decided the threshold for a child protection plan was met and so there no evidence that the process was unfair.
The decision for the children to be subject to a child protection plan was based on the threshold for significant harm and not alternative support that could be provided.
The decision of the review CPC in April was that the children should remain subject to child protection plans supporting the original decision.
The Council noted this was its final response to her complaint, but if Ms X remained unhappy she could escalate her complaint to the stage three appeal panel, which Ms X decided to do.
This panel meeting took place in mid-September. This was chaired by an independent chair and attended by representatives from the police, Council and health as well as Ms X. The panel found: The ICPC was conducted in line with statutory procedures and the London Safeguarding Children Procedures. It involved an appropriate range of professionals, and the conference was not dominated by any single agency.
The chair and attendees demonstrated professionalism and integrity.
An advocate would have been beneficial for Ms X, but she could have asked to delay proceedings to seek this service.
The categories used in an CPC are defined nationally and a panel must select from these based on the evidence presented. It was satisfied that, based on the information available, the category was applied correctly according to national definitions.
The threshold for a child protection plan was met, and it did not uphold any of Ms X’s complaints.
The Council wrote to Ms X at the end of September with the outcome of the stage three appeal meeting. It noted it supported the original decision of the ICPC and did not uphold her complaint.
It also noted that although Ms X’s complaint was not upheld, the panel identified some areas for reflection to improve practice, which included providing clear messages about advocacy services, ensuring reasonable adjustments are considered in all cases of neurodivergent children and exploring support for families in navigating working with multiple agencies. These were not in response to a finding of fault and were learning points only.
Findings
The Council has signed up to the London Child Protection Procedures, which sets out how a council should respond to complaints about child protection conferences. The Council followed this procedure when processing Ms X’s complaint and so there was no fault in its approach to responding to her complaint.
It is not for the Ombudsman to say whether the Council was right or wrong to implement a child protection plan. That is for the Council to decide. Our role is to make sure the Council followed the processes and properly considered all the available information when it made these decisions.
As the Council told Ms X, the procedures as outlined in paragraph 30 of this statement say the Council does not have to share confidential police information with the parent directly before a child protection conference and so I find no fault in the Council failing to do so before the conference.
The Council followed the process set out in government guidance, as well as that set out in the London Child Protection Procedures. It involved other agencies, gathered information and involved Ms X and the children. The Council held a review conference in April 2025 where all but one professional again decided the children should remain subject to a child protection plan.
Ms X's complaint was considered at all three stages of the child protection complaints procedure, concluding with a review by an independent multi-agency panel with no prior involvement in the case. The panel considered the evidence and relevant procedures and supported the decisions made at the child protection conferences. Where a complaint has completed the child protection complaints process, including independent review, we will not normally re-investigate unless there is evidence the process was flawed.
I have seen no evidence the complaints process was flawed. The Council considered each aspect of Ms X's complaint, and the independent panel referred to relevant procedures and case records when reaching its conclusions. Furthermore, Ms X has not complained about any procedural shortcomings in the handling of her complaint. In these circumstances, it is unlikely further investigation by the Ombudsman would add anything significant or achieve a different outcome. Therefore, I have found no fault in the way the Council considered Ms X's complaint.
I welcome that the complaint process included practice reflection and how it could improve communication and advocacy for families in the future, despite it not making any findings of fault.
I recognise Ms X feels the impact of the children being made subject to a child protection plan caused her and her family a significant injustice. However, as I have not found procedural fault by the Council, I cannot recommend a remedy for the injustice which Ms X describes.
Investigator's decision on behalf of the Ombudsman