215. In considering Mrs Prices [Mrs Lawence's] complaint to me I have been mindful that the events chronicled above span a lengthy period, during which three complaints by Mrs Price about aspects of the Councils actions have been handled under the statutory Social Services complaints procedure. Two of
her complaints progressed to Stage 3. Many of the key issues have therefore already been subject to scrutiny.
216. The findings of these previous investigations have assisted my consideration of the complaint. With the exception of the investigation into Complaint 1 Stage 1, the investigations themselves appear to have been properly conducted. The Investigating Officer (IO) for Stage 2 of Mrs Prices Complaint 2, in particular, is a well-known and widely respected social work professional. I have therefore decided to have regard for the
findings reported by the IOs at Stage 2 and the Review Panels at Stage 3 in reaching my conclusions.
217. Although the particular events which caused Mrs Price to bring her complaint to me took place in the spring of 2002, in order to understand the context in which those events occurred it has been necessary to look back at the earlier involvement of the Councils Social Services department with Mrs Prices family.
218. I am immediately struck by the difference between Mrs Prices and the Councils perceptions. Mrs Price was unaware that her family was being supported by a plan in 2001 or had been the subject of a strategy meeting, reviews of which would periodically take place. She therefore had quite a different idea of the purpose of the meeting which took place on 13 March 2002 from that put forward by the Council.
219. The trigger for the events which were to lead to Mrs Prices complaint to me was a heated argument between her and her former partner, Mr Moore, at that meeting. In the course of the argument Mr Moore was heard to say that Mrs Price sometimes hit the children with a wooden spoon. The clinical psychologist (Jane Smith), who was present at the meeting, subsequently expressed concern about the way in which the parents might be behaving when unobserved. This led social workers to initiate inquiries.
220. It is clear that in doing so the social workers failed to follow the appropriate procedures in various respects. One such failure was in recording details of the referral on the appropriate form. The failure properly to record the decision-making process was maladministration in itself. It has made it difficult to ascertain precisely what suspected significant harm had led to the social workers inquiries. It is nevertheless clear to me, from the available evidence about the interviews with Mrs Price and her children, that the subsequent investigation sought only to establish whether the children were at risk of physical harm if Mrs Price was in fact administering corporal punishment with a wooden spoon.
221. I do not criticise the social workers for the decision to make inquiries. However, the IO in his report on Stage 2 of Mrs Prices Complaint 1 concluded that there had been numerous faults in the way in which those inquiries had been conducted, including in particular the failure to undertake adequate preliminary inquiries before speaking to Mrs Price. I concur with his conclusions. In my view, had the preliminary inquiries been made properly they would have shown that Jane Smith had referred the family to the Child Protection Team on similar grounds a year previously, when a strategy meeting had been held and concluded that there were no child protection issues; that since then the only new developments had been the breakdown of an already strained relationship between Mrs Price and Mr Moore, and mention of use of a wooden spoon for punishment; and the latter concern had already been known to Social Services for about a week.
Had these facts been recognised before social workers were dispatched to speak to Mrs Price it is unlikely that the interviews with her and with her children would have been conducted in such a precipitate, not to say
222. In my view the way in which Mrs Price and her children were handled during the course of the inquiries was unacceptable. Specifically, to have entered Mrs Prices shop and to have accused her in front of her daughter, and to have insisted on picking the children up from school where their teachers, their friends and their friends mothers would be witnesses to the event, was grossly insensitive and unnecessarily indiscreet. Moreover, the social workers sent to pick up the children from school then made a hash of it in a way which defeated the purpose of the exercise, namely to prevent them from being influenced by contact with their mother. They attempted to transport illegally four children with two social workers in a five-seater car - when one of them had been left with her mother for the afternoon and they had all been kept waiting for ten minutes with their mother before the social workers arrived late - then had to agree to the mothers taking them to the interview, unsupervised, in her car. This was incompetence.
223. As a result of the maladministration identified in the preceding paragraphs Mrs Price and her children suffered distress, embarrassment and humiliation. Whilst the Council did formally apologise to Mrs Price (Officer Is letter of 19 August 2002) the apology was in bare terms which did not acknowledge the degree of distress experienced by Mrs Price and her children. A more heartfelt apology at that stage might have done much to alleviate the hurt and anger which Mrs Price has continued to feel, and which have in my view driven her to pursue her complaint over two and a half years.
224. Mrs Price was very angry and anxious following the events of 13 March 2002. She made great efforts to find out how she could right what she saw as the wrong that had been done to her family. Although the family was supposed to be receiving support from social services, there is no evidence that she was supported or assisted in this by social work staff. Officer C visited the family home on 3 April but this was to gather information for the Initial Child Protection Conference (Initial CPC), not to provide support to Mrs Price.
Mrs Price met (at her own request) the Chairman of the Initial CPC before the conference but the meeting did not appear to have given her much understanding of the process.
225. It was thus left to Mrs Prices solicitor to advise her to try to obtain copies of the social workers and the psychologists reports ahead of the Initial CPC. Good practice, identified in Working Together, dictated that the parents should have been provided with copies of the reports beforehand. The Investigating Officer on Stage 2 of her Complaint 2 concluded that it was unacceptable that she was not shown the psychologists report in advance. I note that Officer Cs report had not been prepared until shortly before the meeting. However, the psychologists report was available and in my view it was maladministration on the part of Social Services staff, who were in possession of that report in good time, not to have made it available to Mrs Price at least one day in advance of the meeting.
226. The failure to make available this report well in advance of the Initial CPC meant that Mrs Price was unable to make a considered challenge to what she clearly felt were incorrect statements. She was in any case
left feeling that she had been prevented from fully expressing her disagreement in the conference. I am not in a position to comment on the accuracy of the psychologists report. However, had Mrs Price been given the opportunity of making a considered and reasoned challenge to that report, the conference chairman would have been better placed to distinguish between fact, observation, allegation and opinion - as she was required to do by Working Together.
227. The psychologists very similar concerns about the family had previously been expressed and considered at the strategy meeting in 2001; some of the participants at the 2002 meeting had been present at the 2001 meeting and others had been, or should have been, aware of it. However, none of them informed the chairman of the fact that the meeting in 2001 had been a strategy meeting to consider the same issues, raised by the same person, as were before them at the Initial CPC. The chairman says she had had access only to the front sheet of the case file which summarised the available information about the case. However, her manager stated at interview that Initial CPC chairmen had access to the files if they chose to look at them. If that is so, the chairman also had a measure of responsibility for the failure to recognise the true status of the 2001 meeting.
228. As a result of these failures on the part of participants in the Initial CPC, material under discussion at the 2001 conference was reintroduced without reference to the 2001 meeting or accurate reporting of its contents. The IO at Stage 2 of Mrs Prices Complaint 2 was extremely concerned at this. I agree: that was maladministration.
229. It is likely that the conference would have taken a different course had its members taken cognisance of the decision of the 2001 meeting and the lack of new information since then. The Initial CPC chairman has
subsequently said that she would have handled the conference differently and focused on different issues had she been aware of the 2001 strategy meeting.
230. At the Initial CPC it was accepted that there was no risk of physical abuse; and the chairman said that issues of the welfare and psychological well-being of the children were not to be considered at the Initial CPC but would be raised at a separate forum. It is difficult to understand how, in light of this, the Conference could have taken the decision to place the children on the register of children at risk. The Conference comprised representatives from other bodies as well as Council officers. But it is clear to me that there were procedural and administrative faults on the part of the Council officers concerned which significantly affected the process by which the decision was taken. Bearing in mind the professional opinion of the Investigating Officer, Mr Owen, that the decision had been totally inappropriate, I conclude that on the balance of probabilities, had these faults not occurred, the conference would not have taken the decision to place Mrs Prices children on the register of children at risk. I conclude, therefore, that maladministration on the part of Council officers led to the injustice to Mrs Price and her children of their being wrongly placed on the register of children at risk.
Mrs Price thereby suffered the stigma of being identified as a potential child abuser; Mrs Price says that she and her children were ostracised by the local community.
231. There were significant shortcomings in the Stage 1 investigation into Mrs Prices complaint 1 which were identified by the Investigating Officers report at Stage 2, which was endorsed by the Stage 3 review panel.
In essence, the manager of the officers whose actions Mrs Price had complained about had concluded that there had been no procedural or professional fault in the way in which the previous inquiries had been conducted.
These conclusions, based on an investigation which was described by the IO as insufficiently thorough and containing factual inaccuracies, were incorrect. The shortcomings in the Stage 1 investigation led to the
additional injustice to Mrs Price that she was obliged to continue to pursue her complaint through the remainder of the complaints process.
232. The social worker Officer C failed to contact Mrs Price or her children for ten weeks after the Initial CPC and when he did it was to request her presence at a meeting three days later. I consider this to have been unreasonable. The delay of ten weeks was, in my view, maladministration.
233. Mrs Prices reason for not accepting Officer Cs invitation was that she had a prior engagement with her solicitor. This was in my view a valid reason. There is no evidence that any alternative date had been offered. Officer Cs subsequent report for the first review CPC stated that he had been unable to contact the children since the Initial CPC but my investigator found no evidence of any attempt to do so. Mrs Price had been offered one date out of, by the time she was approached, seven remaining working days following a delay of ten weeks. Given that she felt very strongly that the inquiries made by social workers and the subsequent
decision to place her children on the at risk register should never have happened in the first place, and given that she was doing her best to get the Council to admit its error, the decision whether or not to co-operate was not a straightforward one. In my view she was not given sufficient time to consider her position on a core assessment before the first review CPC. That her ambivalence should be represented (in a report which she was again not given sight of until immediately before the meeting) as a refusal to co-operate with a core assessment was unfair.
234. The All-Wales Child Protection Procedures had come into effect by the time of the first review CPC. The failure to make available to and to discuss with the family the reports of all participating agencies at least 24 hours before this conference was contrary to the requirements of the All-Wales Child Protection Procedures and was maladministration. This maladministration led to the injustice that Mrs Price had, once again, scant
opportunity to make a considered challenge to any of the statements presented to the conference as fact.
235. The closed session held during this conference was to allow the Council to take legal advice on Mrs Prices alleged refusal to co-operate with a core assessment. The Council could have obtained any necessary
legal advice on this point before the meeting. Excluding the parents for part of the Conference for this purpose was contrary to the All-Wales Child Protection Procedures and constituted maladministration.
236. Mrs Price wrote to the Director of Social Services, Officer J, on 11 September and her solicitors also wrote on the following day seeking postponement of the core assessment until her complaints had been finalised. Officers interviewed could not recall the letter or the request. Yet the letter had been passed to a solicitor in the Council who had replied to Mrs Prices solicitor. I am concerned that there was no record of this on the files made available to my investigator or, apparently, to the officers interviewed as part of my investigation of this complaint.
237. The Council did not give clear information to Mrs Price about the appropriate complaints procedure through which to channel her Complaint 2. She had indicated in writing on the day after the conference that she was dissatisfied with the closed session held at the first review CPC and that she wished to appeal the CPCs decision. The chairman of the CPC replied to her fifteen days later on the first point but not the second; another officer wrote to her seven days after that (22 days after the conference, when the chairman was on leave) to say that the appeals process required an interview with the CPC chairman within 21 days of the conference. To have failed to provide prompt and timely information on this point was maladministration and led to the injustice that Mrs Price was prevented from appealing the decision by being out of time.
238. Officer K, the Councils complaints officer, confirmed on 12 August that the conferences have their own procedure for these matters. Yet Officer H, the conference chairman, told Mrs Price on 11 September that her complaint about the CPC would be dealt with under Stage 1 in the Councils complaints procedure. She nevertheless invited Mrs Price to appeal against continuing registration through the All-Wales procedures. In the event, the complaint was not dealt with under either of these but was investigated in a Stage 2-type investigation by Mr Owen, for reasons which were not explained to Mrs Price. I consider that this confusion as to the appropriate procedure under which to deal with Mrs Prices complaint was maladministration, and caused Mrs Price unnecessary additional time and trouble in attempting to pursue her complaint through channels which were unclear.
239. I regard as maladministration the Councils failure to replace Officer H [who just happened to be the wife of the Director of social services] as chairman of the second review CPC held in October 2002. Mrs Price had made a formal complaint about her as chairman of the previous, July, conference. Given the nature of the points of complaint she had identified, there was little prospect of her engaging positively in any further conference chaired by Officer H.
240. Mr Owen, in his report on Complaint 2, upheld Mrs Prices complaint that she had not been given access to any of the professionals reports prior to any of the CPCs. I am dismayed that at this third conference she
was still not afforded sight of them until shortly before the meeting. This was a clear breach of the procedures which had by now been in place for some months and was maladministration. I am also dismayed at the minute which effectively blames the parents for the delayed start to the meeting. The parents should have been provided with, and had the opportunity to discuss, the professionals reports prior to the day of the conference. To have allowed the conference to proceed having failed to ensure that they had had the opportunity to do so; then, having delayed the start of the conference so that they could look at the reports in haste and under pressure, to have effectively blamed the parents for the late start; and to have allowed the conference to take place in the knowledge that other participants would have to curtail their attendance because of the late start all this was incompetent and unfair and constitutes maladministration. The injustice done to Mrs Price at the previous two conferences was repeated yet again: she was obliged to make an extempore response to considered reports which she felt were wrong.
241. The chairman insisted, in the face of Mrs Prices and Mr Moores protestations, that the psychologists report was correct. She was not in a position to do so and indeed Mr Owen, in his report on Complaint 2, stated that she had failed to differentiate between fact, allegation and opinion. In my view the decision to retain the children on the register in October was once again taken by a CPC which was seriously procedurally flawed, and the decision was in any event unreasonable, being based not on any perception of real risk to the children but on Mrs Prices alleged failure to co-operate with input from social care. This was maladministration.
242. The children remained on the register until the following June, when their names were finally removed. The All-Wales Procedures prescribe a maximum of six months between conferences. In this case there was a gap of eight months. This was a breach of the procedures and was maladministration.
243. During the time they were on the register of children at risk, Mrs Prices children could have expected a measure of protective vigilance from Social Services. This was not forthcoming: for example, on at least one
occasion an entire month elapsed (from 17 January to 18 February 2003) between Social Services receiving notification of a head injury to one of the children and social workers seeking contact with the child, and a further delay of 19 days before an interview with the child was scheduled.
244. My predecessor had invited the Council to consider making a remedy to Mrs Price for the shortcomings identified in respect of her complaints 1 and 2. It is disappointing that the Council failed to agree a suitable
remedy with Mrs Price. In particular, I note that the Council appeared to think only in terms of financial recompense, not of making a fitting apology for its shortcomings. Moreover, it decided not to offer any payment unless and until Mrs Price specifically asked for one.
245. The Councils solicitors letter to Mrs Price dated 15 December 2003 asked Mrs Price to explain why she was sending copies of his correspondence to me when they were marked without prejudice. I consider
this to be highly inappropriate: any complainant is entitled to send me a copy of any correspondence whatsoever with the council.
246. To sum up: the track record of the Council in dealing with Mrs Price and her children has been lamentable. Things first went badly wrong when its officers carried out a clumsy and insensitive investigation which unjustifiably resulted in an Initial Child Protection Conference. That CPC was procedurally flawed and took an unreasonable decision to place the children on the register of children at risk. Whereas some support had been provided to the family before this, all assistance then ceased. The most important aspects of Mrs Prices complaints were vindicated by successive investigating officers and review panels. Consideration of the
recommendations which flowed from the statutory Social Services complaints procedures should have led to prompt action to remove the childrens names from the at risk register. However the review CPCs were seriously procedurally flawed and focused not on the absence of real risk to the children, but on the alleged failure of Mrs Price to co-operate with social services interventions. In effect, Mrs Price was being punished for being difficult and non-compliant. The Council at various times exhibited confusion in its handling of Mrs Prices various complaints, appeals, and representations. Its approach to making redress in respect of the serious complaints which were upheld was grudging and ineffectual.
247. I find that there was repeated, prolonged and serious maladministration on the part of the Council in its dealings with Mrs Price over the registration of her children and that this maladministration caused her, and them, injustice.
248. To remedy the injustice done to Mrs Price I recommend that a full apology be made to her in writing in respect of the serious shortcomings I have identified in this report, together with a clear acknowledgement that
her children should not have been placed on the register of children at risk. I also recommend that the Council make a payment to her of £5,000 in recognition of the severe distress and the reputational damage which its
maladministration has caused her and of her time & trouble in pursuing her
complaints with the council and with me. The Council should also, through their mother, say sorry to the children.
249. To reduce the risk of a similar injustice happening to another family, I recommend that the Council should by no later than the end of June 2005 carry out a formal review, with external assistance, of the lessons to
be learned from the events described in this report. The Council should then implement promptly and vigorously any improvements required to its procedures or to the training of its social care staff.
250. The Council will now have to give formal consideration to my report; however I am pleased to say that the Council has given an initial indication that it will be minded to accept and implement in full my
recommendations at paragraphs 248-249 above.
20 December 2004