Below is the report of the Ombudsman into the complaints made by "Mrs Price" against Pembrokeshire County Council's social services department.
The full report covers 47 pages and, for those who haven't the time, or the inclination, to read the whole thing, the Ombudsman's conclusions and findings begin at paragraph 215.



Report by the Commissioner for Local Administration in Wales

(Local Government Ombudsman) on an investigation into a complaint of
maladministration made against Pembrokeshire County Council


1. Mrs Price is the mother of four children from whose father she is
separated. She complains that the Council’s Social Services department
unnecessarily and insensitively conducted an investigation into her
treatment of her children; that at a subsequent Child Protection Conference
(CPC), on the basis of incorrect and misleading information, the children
were placed on the register of children at risk; that her complaints about
the initial investigation and the child protection conference were not
properly dealt with and that the children were wrongly retained on the
register and eventually removed therefrom on spurious grounds. As a result
of the Council’s actions she says she has suffered the injustice that she
and her children have been stigmatised and ostracised from the small
community in which they live, she has lost the business she ran and she and
her children have suffered distress and anxiety.

2. For legal reasons, the names used in this report are not the real
names of the people and places concerned.

3. An officer of the Commission has visited the complainant, has
examined Pembrokeshire County Council’s files and has interviewed officers
of the Council.

4. An opportunity has been given for the complainant and
Pembrokeshire County Council to comment on a draft of the factual part of
this report prior to my finalising the conclusion.

Legal & Administrative Background

Child Protection Procedures

5. During the period covered by the events which led to Mrs Price’s
complaint there was a change in the formal procedures governing child
protection. The procedures in operation from September 1998, the “West
Wales and Powys ACPCs Child Protection Procedures” were superseded in June
2002 by the “All-Wales Child Protection Procedures”.

Working Together to Safeguard Children, 1999

6. “Working Together” states that parents should normally be invited
to CPCs and helped fully to participate (paragraph 5.57). Conference
chairmen should ensure that conferences take decisions in “an informed,
systematic and explicit way” (5.59). The Social Services report to a CPC
should be provided to the parents and children, and explained and discussed
with them, in advance of the conference (5.61). It is good practice for
other professionals to provide a written report in advance which should be
made available to those attending (5.62). All those providing information
should take care to distinguish between fact, observation, allegation and
opinion (5.63).

7. “Working Together” distinguishes between the process of the
conference, the outcome in terms of the fact of and/or the category of
continuing registration and a decision not to register or to deregister, as
matters about which parents may complain and states that complaints about
aspects of the functioning of conferences should be addressed to the
conference chair and passed on to the Social Services department for
response; the department should form an inter-agency panel of senior
representatives which should consider whether the relevant protocols and
procedures have been correctly observed and whether the decision followed
reasonably from the proper observation of the protocol.

West Wales and Powys ACPCs (Area Child Protection Committees) Child
Protection Procedures: September 1998 - June 2002

8. These Procedures require anyone who has concerns that a child is
being harmed or is at risk of significant harm to refer their concern to
Social Services or to the Police, both of which agencies have statutory
duties and powers to investigate and intervene. The agency receiving the
referral must record comprehensive details on a form, Form A95, which is
intended to ensure that a complete record is maintained of the decisions
taken at each stage of the investigation and which must be signed by the
senior social worker and by the detective inspector or sergeant. If the
agency receiving the referral is Social Services, its officers should make
certain inquiries, including checking any other records. If Social Services
are then satisfied that there are sufficient grounds to warrant
investigation they should discuss the referral with the police; following
this “strategy discussion” a decision will be made as to whether the
investigation will be undertaken by the police, by Social Services or
jointly by both, depending on the seriousness and type of abuse.

9. The procedures state that “when investigating allegations or
suspicions of abuse or neglect, it is critical to have a detailed history of
a child/ren and their family… detailed information will be available within
the records of agencies which know the family. It is the responsibility of
each agency to contribute all the information held in the records when
requested, not just edited highlights.”

10. The procedures state that in circumstances where the investigation
reveals no substance to the cause for concern, the investigating social
worker must inform the parents of this and confirm this assessment with the
team manager who will reach a joint decision with the police that no further
action is required.

11. In such situations the distress and inconvenience caused to the
family must be acknowledged. However if the investigating social worker
reports to his or her supervisor that “there is evidence to indicate that
the child is likely to have been abused and/or is at risk of abuse” the
Social Services team manager will convene a Child Protection Conference.

12. A CPC is a forum at which the family and representatives of all
agencies with specific responsibilities in the child protection process
share information and, where appropriate, agree a multi-agency child
protection action plan. The Social Services team manager will normally
convene an initial CPC within 8 working days of the referral or, if there
are special reasons why the initial investigation has not been completed
within the timescale, within a maximum of 15 working days of the referral.
If the CPC decides that a child must be registered, Social Services should
convene a review conference within a maximum of three months of registration
and subsequent review conferences should be held within a maximum of six
months while the child is registered or if there are significant

13. Social Services issue invitations to those attending a case
conference. Written invitations to parents “should be in the form of a
personal letter and should be accompanied by an agenda and any other
relevant information”. The procedures advocate the provision of an
information leaflet at this stage. The procedures also state that it is good
practice for professionals to discuss their contribution to the conference
with the child’s parents prior to the conference where time and
circumstances allow.

14. The objectives of an initial CPC include “to establish and
evaluate all relevant facts about the child and family. Conference members
should check that the basic information known about a family… are accurate
and complete…”

15. The tasks of the CPC chairman include meeting the family members
in advance to explain the process and answer any questions; and to ensure
that the protection plan is agrees and clearly understood by all agencies.

16. The procedures stress that the case conference should seek that
“the most accurate perspective of life within the household is presented and
considered in any decision making process”.

17. If the CPC decides to place the child’s name on the register of
children at risk a core group meeting should be called within 10-15 working
days “to prepare a comprehensive assessment”.

18. The reports prepared by participants for CPCs are expected to
“provide information relating to [the] agency’s knowledge of the child,
their family and family networks which would assist in determining the level
of risk to a child” and should be provided to the chairman in advance of the
conference. The social worker’s report is expected to provide, inter alia,
information about any previous referrals.

19. A key worker is appointed at a case conference. This person’s
duties include visiting the child and family, ensuring that in all matters
agency procedures are complied with; seeing the child regularly according to
the assessed needs of the case; and co-ordinating the multidisciplinary
child protection plan and ensuring its regular review. The key worker’s
team manager is expected to supervise and ensure that the key worker fulfils
these duties.

20. A core group established at the initial CPC comprises professional
and voluntary workers most closely involved with the welfare of the child.
At its meeting within 15 days of the initial case conference the group is
expected to plan in detail the work outlined in the CPC recommendations and
to produce an agreement signed by the family and those professionals
involved in implementing the plan. The core group should then continue to
meet at least once between CPCs. The presence of the parents is desirable
but not essential.

21. The CPC chairman should inform the parents and, understanding
allowing, the child, of their right of complaint in relation to the actions
of individual agencies. In case of a complaint the key worker should be
notified by the agency concerned and a Child Protection Review Conference
convened where the implementation of the child protection plan is
significantly affected.

22. The procedures give details of how to appeal against registration
or de-registration in respect of Carmarthenshire only. In respect of
Pembrokeshire the procedures state only that “details relating to the
Complaints Procedure for anyone dissatisfied with the way a case conference
was managed will be made available by the Chair of the conference”.

All-Wales Child Protection Procedures: June 2002 onwards

23. The All-Wales Procedures (3.3.1), which came into effect in June
2002, state explicitly:- “Where a referral is received about a child already known to Social
Services, a great deal of information will already be available. Decisions
made following the new referral must take account of all the known
information and the work currently being undertaken.”

24. Paragraph (“Exclusion”) states that at the chairman’s
discretion parents may, exceptionally, be excluded from all or part of a CPC
if one or more of the following applies: there is a strong risk of
intimidation of anyone by a family member and his or her presence might
seriously disrupt the conduct of the conference; there are implications for
criminal proceedings for one of the parents as an alleged perpetrator; or
the child states that he or she does not wish the parents to be present.
Any professional can request the exclusion of a parent; the chairman should
discuss the request with the relevant agency manager before reaching a

25. The procedures state that parents might need help in preparing for
the conference and the chairman should meet them beforehand to explain how
the meeting is to be conducted. The chairman should, if the parents
disagree with the conference decision, tell them about the ACPC complaints

26. The Procedures (3.8.6) state that each agency should provide in
advance a written report and should arrange to discuss the report with the
family at least 24 hours before the conference.

27. The Procedures (3.8.12) state that “complaints about the
functioning of the conference should be addressed to the conference chairman
who will pass the complaint on to the senior manager for child protection in
Social Services; in considering and responding to complaints about
functioning and decision making processes of the conference, the local
authority should form an inter-agency panel made up of senior
representatives from ACPC member agencies; this panel should consider
whether the relevant inter-agency protocols and procedures have been
followed and whether the decision that is being complained about follows
reasonably from the proper observations of the procedures. Complaints about
individual agencies, their performance and provision/non-provision of
services should be responded to in accordance with the relevant agency’s
complaints procedures.”

28. Appendix 9 of the All-Wales Procedures (“Handling complaints from
families about the functioning of CPCs. The Appeals Procedures”) states
that whereas complaints about individual agencies should be routed through
the agency’s complaints procedure, complaints about the decision to register
or deregister, and about the category of registration, should be addressed
to the ACPC using its Appeals Procedure. This procedure requires the
aggrieved party to seek an interview with the chairman of the conference
within 21 days of becoming aware of the decision, to discuss the reason for
the decision and his or her grievance; the aggrieved person can be
accompanied by a supporter or a solicitor; if the person remains aggrieved
he or she should notify the ACPC Chairman, in writing within 10 days of the
meeting with the CPC chairman, of his or her wish to appeal. Within 10 days
of receiving the notice of appeal, the ACPC Chairman will convene an appeals
panel comprising one senior Social Services representative, one health
representative and one or two other persons experienced in child protection,
and a hearing will take place.

29. The procedures state that the above time limits may be extended by
mutual agreement between the parties.

The statutory Social Services Complaints Procedure

30. Local authorities have a duty to maintain a separate statutory
complaints procedure for complaints that relate to children in need of
services that it can provide. It is a three stage procedure and if after
each stage complainants remain dissatisfied, they can take their complaint
to the next stage. Stage 1 is to provide information and to attempt
resolution; Stage 2 is a formal investigation; and Stage 3 provides a review
of the complaint. The complaints procedure provides for an independent
person to monitor the process at Stages 2 and 3. The procedure contains the
following time limits: Stage 2 – up to 28 days; Stage 3 – up to 28 days; and
then 28 days for the local authority to decide if it will accept any
findings of the Review Panel (Children Act 1989 Section 26).

Report of the Joint Review of Social Services in Pembrokeshire

31. A Joint Review of Pembrokeshire Social Services was carried out by
a team working on behalf of the Audit Commission and the National Assembly
for Wales. The team was working in the Authority from January to March 2002
and its findings were presented to the Council in November 2002.

32. The Report (3.5) states, in respect of assessment and care
planning of children in need:
“The Department has implemented the Framework for Assessment 12 months
earlier than required. However it was implemented against a background of
considerable disruption in the two children’s teams, with investigations
into bullying taking place. This affected staff morale, and management
changes meant that staff were not always receiving regular supervision. In
addition, there is not a history of staff undertaking assessments, which was
evident from the case files… the Assessment Team was finding it difficult to
meet the timescales for completing initial and core assessments… some files
contained poor quality initial assessments and there was evidence that poor
planning had in some cases led to situations deteriorating.”

33. The Report (3.5.2) states, in respect of Child Protection:
“…the care plans seen on file in child protection cases were very sparse and
limited to what was produced at the conference, which is not adequate”.

Background to the complaint: chronology of events

Events prior to 2002

34. Mrs Price and her partner Mr Moore moved into the Council’s area
in 1991. They have four children. The Social Services files record that
the first contact with the family was as a result of concern over habitual
lateness at school in 1997, when the Council’s file includes a note stating
“Mother alleges domestic violence, parents may split up”.

35. One of the children, Paul, has suffered from an early age from a
bowel control problem. The Social Services file indicates that in late 1999
this caused him to be admitted to the local hospital. The specialist
treating him there, apparently being unable to find a physical cause for the
problem, referred him to a clinical psychologist, Jane Smith, in case the
problem was of psychological as opposed to physical origin. The Social
Services file on Paul records a referral dated 10 August 2000 by a Zoe Evans
at the local hospital requesting a strategy meeting on the grounds that
there were child protection issues, but there is no record of any follow-up.
The files show that Officer G, a senior social worker, discussed the child
with Jane Smith on 18 October 2000 and recorded “Paul’s problem behavioural
not medical… No CP [Child Protection] issues so no reason to insist on SSD
[Social Services Department] involvement”. During the course of her
clinical investigations Jane Smith interviewed Mr Moore and Mrs Price. Mrs
Price says that she was completely open with Jane Smith about and in the
course of her sessions with her had told her about a drink problem she had
formerly experienced and had recounted to her various remarks made by her
(Mrs Price’s) father to the effect that Mr Moore “would end up killing her”.
Mrs Price says that at this time, relations between Mr Moore and her had
been strained.

36. Jane Smith referred the family to the Social Services Child
Protection Team on 22 February 2001, expressing concerns about the safety of
Mrs Price and her children. Social Services convened a strategy meeting on
20 March 2001. The minutes of the meeting state that Jane Smith said that
“Mrs Price had not mentioned any physical threats” and a police officer
present had confirmed that “there were no child protection issues”. The
police were to make further inquiries and, if there were any concerns, would
inform the chairman. A “plan for support”, specifically not for child
protection, was agreed at this meeting. As part of the support package,
strategy meetings were arranged from time to time. Mrs Price was unaware
that the meeting on 20 March 2001 had taken place. She had no idea that
there was any plan or that her family was being periodically reviewed at

37. The Social Services files record that a Project Worker, was on 29
June 2001 assigned to work alongside Mrs Price with regards to
toilet-training Paul. In her comments on the draft factual part of this
report, Mrs Price states that no project worker was involved with her

38. Anne, Mrs Price’s and Mr Moore’s eldest daughter, had also begun
to experience problems and she also was referred to Jane Smith. Jane Smith
was unable to provide a solution to Paul’s problem. However the family was
assigned a Community Support Nurse who,, Mrs Price says, was helpful.

39. The Social Services files indicate that Jane Smith, the Community
Support Nurse and another social worker met on 22 October 2001 and, as Mrs
Price had “been persuaded to accept support” agreed that an application
should be submitted for a family support worker. However, there were “no
family support workers available for this work” and a project worker was
suggested together with the convening of a Child in Need meeting.

40. Jane Smith wrote to the specialist who was dealing with Paul at
the local hospital again expressing concerns.

41. Mrs Price says that the Community Support Nurse suggested that, as
she was due to leave her post, it would be helpful to Mrs Price to have help
in the form of a specially trained caseworker who could help Paul with
toilet training. Mrs Price understood her to say that Officer A was such a
person and agreed to her coming to help Paul.

42. The Council’s files include a note dated 10 December 2001 stating
that the family was being supported by a Paediatric Community Nurse who was
being assisted by Officer A, a social work assistant “whose role is to
continue to support Mrs Price and assist with Paul’s refusal to take his
medicine at home”. This note bears the superscription “Agreed transfer” and
is signed by Officer G, Senior Social Work Practitioner. A further note
signed by Officer F, Assistant Co-ordinator, states that the case was
allocated to Officer A.

43. Social Services’ files record that Officer A, a social work
assistant, took over the case on 9 January 2002. Mrs Price says she was
surprised when she first saw Officer A as she seemed unexpectedly young and
inexperienced given the nature of the task Mrs Price understood her to be
appointed to undertake. In the event, she says Officer A had provided no
help to Paul at all and only said hello to him twice. Social Services
officers interviewed as part of my investigation said that it was not the
Council’s usual practice to assign overall responsibility for cases to
unqualified staff. The Head of Child Care Commissioning said at interview
that his instructions were that the case management responsibilities of
unqualified staff should be minimal.

44. There is no indication that Officer A has any expertise in the
area of bowel training, nor, at this stage, that she was expected to carry
out any particular support duties in respect of Paul. Nevertheless she
visited the family home and compiled file notes of her observations. One
such observation, made on 6 March 2002, includes the comment “[Mrs Price]…
told me… an argument ensued and [Mr Moore] is said to have hit [Mrs Price]
across the head in front of [two of the children]… seemed to take [Mr
Moore]’s outburst as a regular consequence…”

The meeting on 13 March 2002

45. In early 2002 matters came to a head within the family as Mrs
Price discovered that Mr Moore was emotionally involved with someone else.
There had been arguments, including one which reportedly involved Mr Moore
hitting Mrs Price in front of the children. He had left the family home.
Mrs Price was running a shop and trying to look after the family. This was
proving difficult without Mr Moore at home to participate in childcare
arrangements. Mrs Price says she suggested that a meeting be held, including
Officer A, Mr Moore and herself, with a view to easing the situation. The
meeting took place on 13 March 2002. According to the Council’s files,
however, this was a review meeting of the strategy meeting which had been
held on 20 March 2001. According to the findings of the Investigating
Officer who investigated at Stage 2 of Mrs Price’s Complaint 1, the meeting
had been convened by Jane Smith to discuss future plans for Paul. According
to an official complaint form later completed by Mr Moore, his understanding
of the purpose of this meeting was to set up a series of group family
meetings to re-establish family rapport.

46. Those present at the meeting were Mrs Price, Mr Moore, Officer A,
Jane Smith and the Community Support Nurse. Officer A’s notes indicate that
the purpose of the meeting was “to discuss progress and ways of moving
forward intervention”. Mrs Price says that at this meeting Mr Moore had not
been in a positive frame of mind as he “felt he had been conned” because she
had brought up the question of looking after the children at weekends.
There had been an argument between them and she had stated that he had hit
her and had inadvertently hurt the eldest child in the process. Mr Moore
had then made a remark, in the context of the behaviour of one of their
other children, to the effect that Mrs Price hit him with a wooden spoon.
Mrs Price says that although Jane Smith had expressed concern that such a
heated argument had occurred in the context of the meeting neither she nor
Mr Moore thought much about the exchange; in any event she had mentioned to
Officer A about a week previously that she had had occasion to threaten the
child with the spoon for being very rude (and Officer A had noted this on
the file of one of the other children). Mrs Price and Mr Moore discussed it
briefly and dismissively in the car they shared for part of their way home
from the meeting.

47. Officer A’s notes of the meeting record Jane Smith’s concern, in
view of the way the parents had behaved at the meeting, “at what was
happening at home” and that she herself would have to “discuss the way
forward” with her supervisor. There is no record of such a discussion. It
was later asserted by the Child Care Operational Manager, Officer E, that
following the meeting Officer A had discussed the matter with Officer F,
Customer Service Manager, who had telephoned Jane Smith, the psychologist,
and agreed that the children should be spoken to.

The social workers’ visit to Mrs Price’s shop

48. Later that day, a social worker, Officer B, accompanied by Officer
A, went to the shop Mrs Price ran and, Mrs Price says, accused her in front
of her daughter Anne of child abuse in that she had hit Paul with a wooden
spoon. Mrs Price says Officer B’s manner was intimidating and hectoring.
Anne was frightened and upset. She herself was upset. Customers had
telephoned the shop during the course of the exchange and she had to put
them off, and had had to close the shop while the exchange was taking place.
Officer B’s note of the meeting records that the threat of the wooden spoon
was Mrs Price’s means of disciplining the children and that the children
would sometimes laugh at it.

49. Mrs Price says that the social workers were determined to
interview her children. She says she agreed, very reluctantly, to this
because they told her she could not refuse, but refused to agree to their
being interviewed at school, because it would be humiliating for the
children. The social workers left the shop and, according to Officer B’s
notes, their manager, senior social worker Officer F, telephoned the local
police and took a decision to talk to the children together with the police.
She then telephoned Mrs Price. Mrs Price says she insisted on interviewing
the children at school although Mrs Price said they could be interviewed
later at home or in some place other than at school. The Council’s files
show that Officer F tried to explain that social workers needed to interview
the children before the children were seen by their mother and that the
social workers would be at the school at an appointed time, but Mrs Price
was still very unwilling and put the telephone down on her. Officer F
accordingly telephoned the local police and held a strategy discussion with
them by telephone.

The interviews with the children

50. Mrs Price says she went to collect her children from school at the
time when the social workers had said they would be present to interview the
children. The social workers were not there. Two social workers arrived
ten minutes late and appeared to be about to take the four children in a
five-seater car to the place where they were to be interviewed. Mrs Price
objected to the children being transported illegally and in the end she took
them in her car. She says the children were very anxious and asked her what
was going on. When she replied that she thought it was about Mr Moore’s
remark that she hit the children with a wooden spoon, the children relaxed
and said “oh, that!”. On arrival at the house she says she was taken by the
arm and steered into a room while the children were taken to another room
where Section 47 inquiries were conducted by the police and two social
workers. She says she was confident that her children’s testimony “cleared
her” at that meeting.

51. The Council’s files record that all the children were interviewed
by social workers and by the police. The child in question said he had been
hit with the spoon, but his sister said that he had only been threatened.
Mrs Price was also interviewed by Officer F and had said that she intended
to continue to use this method to discipline her children, and also that Mr
Moore had inadvertently hurt one of the children during an argument with
Mrs Price earlier in the month. Officer F’s notes record that “given the
details of the incident” a Child Protection Conference “would probably be

Events after 13 March 2002

52. Mrs Price says that two days later she telephoned Officer F who
told her that a CPC was to be held. Officer F has not been interviewed but
it appears that the decision to hold a CPC was taken by her, possibly in
conjunction with Officer B. Mrs Price says that the family were in a state
of panic and anger; she heard nothing further from Social Services and
started to look for a solicitor.

53. Officer A confirmed to Mrs Price on 2 April 2002 that Officer F
had agreed that she (Officer A) should “continue [her] work with [Mrs Price]
looking at [Paul]’s toileting issues in conjunction with the Community
Support Nurse”. Mrs Price was not happy that Officer A should continue to
visit her home.

54. Officer C, a social worker, on instruction from Officer F, made a
home visit to the Price children on 3 April to see the children with a view
to taking the case to a CPC and to establish their “wishes and feelings”.
He says he tried to explain to Mrs Price at this time what was to happen
next, ie that the children’s wishes and feelings would be reported to his
manager and that a CPC might be convened; but he says much of the visit was
spent in listening to Mrs Price.

Mrs Price’s Complaint 1

55. Mrs Price made a formal complaint about failure to follow
procedures and about the attitudes of Officer B and Officer F (Complaint 1).
This was acknowledged on 8 April 2002, recorded as a complaint at Stage 1
and was scheduled for investigation by Officer E, Principal Operations
Officer (Child Care), the manager responsible for the team. Mrs Price was
promised a response by 6 May.

The Initial Child Protection Conference

56. Officer H, who was at the time the manager of Child Protection
Co-ordination and Quality Assurance and who chaired all CPCs, says the
standard letter inviting parents to a CPC indicates who the chairman is and
how he/she is contactable. Mrs Price had asked to see her, as chairman, and
they had met on 11 April. Officer H says she gave her a copy of the “Child
Protection Procedures” and a copy of “Working Together” and talked her
through it. Mrs Price had asked her if it would be possible to have a
“two-tier” format to the conference such that she would have the opportunity
of saying certain things without her former partner being present. She had
obtained the impression that Officer H had agreed to this. Officer H says
the meeting lasted over an hour but Mrs Price disputes this.

57. Mrs Price wrote to Officer J, Director of Social Care and Housing,
on 11 April 2002, copied to several other recipients including the Chief
Executive and her MP, expressing her distress at how she and her children
had been treated by Social Services, stating that she had had no support or
offer of assistance, and asking for an urgent appointment with him to
discuss her report on the events of 13 March, which she enclosed. She wrote
on 12 April to the Chief Executive, copied to Officer J, protesting strongly
about what had happened to her and her children on 13 March. She summarised
this in a letter to the complaints officer dated 15 April as “our local team
of social workers not only rounded up an innocent mother of 4 children in
the public view of her own shop but then insisted to prolong the agony at
the children’s school in front of mothers, teachers and friends”.

58. An Initial Child Protection Conference (ICPC) was held on 17 April
2002, some 23 working days after the referral. Mrs Price had contacted a
solicitor who had advised her to obtain the psychologist’s and the social
worker’s reports prior to the conference. She had been unable to obtain the
psychologist’s (Jane Smith’s) report beforehand and received the report of
the social worker, Officer C (Child Care Assessment Team), only on the day
before the CPC after, she says, considerable resistance. The psychologist’s
report was not made available to her until some five to ten minutes before
the start of the CPC. She and Mr Moore both strongly contested the truth
of several assertions which purported to be factual in the psychologist’s
report and felt aggrieved that the report was accepted by the conference as
fact. Both made substantial spoken contributions at the conference but
subsequently said they had been prevented from making further points they
felt it important to make and had been told repeatedly to be quiet.

59. The social worker, Officer C, says the reason he did not show Mrs
Price a copy of his report at an earlier stage was that he had only been
able to write it shortly before the conference due to pressure of work. He
was not aware, at that stage, of any need for other professionals’ reports
to be shown to the family beforehand. In respect of the content of his
report he says that after he had visited the family he was satisfied that
there was no danger of physical harm to the children and that the wooden
spoon had been used as a threat. However, he says that during his visit to
the house Mr Moore and Mrs Price had had an argument. Mrs Price, in her
comments on the draft factual part of this complaint, denies that she and Mr
Moore had argued with each other on this occasion although they had both
complained to Officer C about the requirement for the children to be
questioned. Officer C says the eldest child had also mentioned that the
parents argued and that this had an effect on the children. He says that
he felt that they might be affected emotionally. He says he was conscious
that he had little information on which to form a view and he therefore
tried to make his report as objective as possible so that the conference, in
light of that and of any information contributed by other participants,
could judge whether the emotional effect of the parents’ arguing was of a
sufficient level to amount to abuse; he was effectively saying “This is what
I’ve got, I think it’s sketchy, what do you think?” Mrs Price disputed
several points in his report, although not his conclusion that any emotional
needs and difficulties on the part of the children were largely due to the
relationship difficulties of the parents.

60. The minutes of the CPC show that 17 persons were present including
the chairman, Officer H. The notes specifically record that there was no
concern regarding physical harm to the children. In respect of their
emotional wellbeing, no fresh information since the 2001 referral had been
adduced. No-one at the conference mentioned that a strategy meeting had
been held following a referral in 2001 to consider the information available
at that time or that the meeting held on the morning of 13 March 2002 had
been (according to the Council’s files) a review of that strategy meeting;
it is referred to in the social worker’s report merely as “a meeting of

61. The notes of the CPC record that Mr Moore had said that Social
Services had not taken the welfare and psychological well-being of the
children into account and that the chairman had responded by saying “those
issues need to be raised at a separate forum”. The notes indicate that when
the chairman called towards the end of the conference for discussion on
registration, Officer G had said that she thought that the threshold for
registration had been met, that there was evidence of significant harm and
that she suggested the children be registered under the category of
emotional harm. Officer G had earlier in the CPC confirmed that, apart from
Officer C’s report, there was no new information from Social Services. The
conference decided to place the children on the register of children at risk
in the category of Risk of Emotional Harm. Officer C told my investigator
that it is a feature of such conferences that once one professional states
that in his or her view a child should be placed on a list it is difficult
for the other participants to express an opposing view.

62. The Minutes of the CPC indicate that it was agreed that a family
meeting was to be held “to resolve difficulties” and that education plans
for the children should continue, but no date was scheduled for the next or
any subsequent meeting. Officer C was named as the Key Worker. The minutes
also state that it was decided that the children’s names should “remain” on
the child protection register.

63. Mrs Price was unhappy about the conduct of the Child Protection
Conference. She says she and her former partner were surprised and
intimidated by finding so many people present and that they had not had
adequate opportunity to read the written submissions before the meeting.
They had certainly not discussed them beforehand with the respective authors
in accordance with good practice as described in the procedures. She said
it had been read out in the meeting that she had “a significant drink
problem” and that she had been “in fear of her life” from Mr Moore. (In
fact what the report states is that Mr Moore had alleged that Mrs Price had
a significant drink problem; that Mrs Price would not be surprised if Mr
Moore killed her and the children; and that if Mr Moore were not kept
“sweet” she would fear for the children’s and her safety.) She had
challenged these statements. She says the first 20 minutes of the meeting
had been taken up with the report by Officer C which had apparently been
based on Jane Smith’s written report and perpetuated assertions made by Jane
Smith and which Mrs Price wished to challenge. She was aggrieved that she
had repeatedly been told to be quiet by the chairman.

Events April 2002 – July 2002

64. There is a manuscript note on the Council’s files ostensibly
signed by Officer I, Head of Child Care, dated 25 April 2002 and addressed
to Officer K, Complaints Officer: “I have discussed with [Officer J] and
[Officer E] dealing. [Officer J] and I have agreed: …registered as
complaint… [Officer J] does not feel it appropriate at this stage for him
to attend a meeting with [Mrs Price]…” The note acknowledges the apparent
seriousness of the complaint. Officer K wrote to Mrs Price on 29 April 2002
advising her that the final part of the complaints process involved the
Director of Social Care and Housing and should the complaint reach that
stage “the complaints process would be compromised if you were to discuss
the issue with him at this stage”.

65. Mrs Price says she was extremely distressed at these events and
their aftermath: she quickly lost custom in her shop and eventually the
business had to close and she and her children have been ostracised in the
small community in which they live. The Council wrote to her on 1 May to
say that the timescale for dealing with her Complaint 1 could not be kept
to, apparently because Officer E had been unable to arrange an appointment
with Mrs Price, and that the date for concluding the investigation had been
extended by two weeks to 20 May 2002. In the event Officer E met Mrs Price
on 3 May at her shop, the meeting being arranged earlier that day.

66. Officer E wrote to Mrs Price on 8 May to give her the result of
the Stage 1 investigation: that “inquiries were appropriately conducted both
procedurally and professionally”. Mrs Price was not satisfied with the
report on her Complaint 1 by Officer E and asked for the complaint to be
considered at Stage 2.

67. She wrote to Officer H, the chairman of the CPC, on 10 May. She
said that Officer H had agreed to a two-tier conference and queried why in
the event Mr Moore had been present for the whole of the CPC. Officer H
replied on 29 May that she had in the end decided not to hold a two-tier
meeting and regretted that Mrs Price had gained the impression that she had
reached a decision on the point when they had spoken. She told my
investigating officer at interview that she did not, in the event, finally
decide until after she had spoken to the family, and particularly to the
eldest child, immediately before the CPC.

68. The investigation at Stage 2 into Mrs Price’s Complaint 1
commenced on 23 May. The investigating officer (IO) contacted Mrs Price on
27 May 2002 to arrange an appointment with her. The file bears a post-it
note saying that he was having difficulty contacting Mrs Price: her
telephone number was “unobtainable”, her shop was closed with signs
advertising a closing-down sale and there had been no response to the first

69. Jane Smith wrote to Mrs Price on 12 June 2002 saying that she felt
it would no longer be useful to continue meeting her.

70. Officer K wrote to Mrs Price on 18 June 2002 inviting her to a
meeting with the IO and Independent Person (IP) on 20 June and seeking her
approval to extend the report date until 17 July.

71. Officer C wrote to Mrs Price on 24 June 2002 (ten weeks after the
initial CPC) seeking her co-operation in conducting a core assessment of
each of the four children, which he said would help to enable the children
to be taken off the register, and asking her to attend a meeting of the core
group identified by the CPC (Officer C, Mrs Price, Mr Moore, the Community
Nurse and the school) on 27 June. Mrs Price received the letter on 26 June
and had already arranged an appointment with her solicitor in a town some 40
miles distant on the morning of the proposed meeting. She wrote back
immediately asking him to cancel the meeting as she felt it important that
she be present but was already committed.

The first Review Child Protection Conference, 8 July 2002

72. The second CPC (ie, the first Review CPC) was held on 8 July 2003.
This was also chaired by Officer H. Mrs Price was not shown the social
worker’s report until immediately before the meeting. The report includes
the comment “[Mrs Price] maintains her stance that she does not wish to
undertake a Core Assessment as she does not believe it to be relevant”.

73. The Minutes note under “Details of any subsequent
injuries/concerns”: “Key worker unable to contact children”. During the
meeting Officer C reiterated that Mrs Price had refused to allow him to see
the children; Mrs Price said that she did not want him to see the children
but was prepared, following advice from her solicitor, to allow him to carry
out the assessment. She had said that he had taken ten weeks to contact her
at all and then had required her presence at 24 hours’ notice. The
conference included a closed session. Officer H told my investigator at
interview that this had been necessary to allow the Council to take legal
advice because Mrs Price would not co-operate with the core assessment and,
although Social Services did not explain this to Mrs Price, an anonymous
telephone call, suspected to be from one of the participants in the
conference, had been received by another participant. The conference
resolved to retain the children on the register and that the core assessment
should be carried out.

74. Officer G wrote to Mrs Price on 9 July 2002 stating that she had
been unable to speak to her after the meeting on the previous day but
enclosing excerpts from the publication “Working Together” as explanation of
the role and purpose of Core Groups and Core Assessments and offering to
meet her with Officer C to explain further should Mrs Price wish.

75. Mrs Price wrote on 9 July 2002 to Officer H, copied to 13 others
including the Chief Executive and Officer J, to query the propriety of
holding a closed session at the CPC, and on 23 July to ask how to appeal
against the CPC’s decision taken on 8 July 2002. She also wrote to Officer
C on 12 July, challenging his submissions to the CPC. Officer H replied on
24 July to say that the closed session had been necessary because the
Council needed to take legal advice about Mrs Price’s (claimed) refusal to
allow her children to be assessed, and a reviewing officer replied on
Officer H’s behalf on 31 July explaining that a CPC’s decision was subject
to appeal by means of an interview with the chairman of the conference
within 21 days, following which an appeals panel would be convened.

76. Officer C wrote to Mrs Price on 31 July 2002 to seek her agreement
to a core assessment being carried out by a third party.

The report at Stage 2 of Mrs Price’s Complaint 1

77. The report of the IO into Stage 2 of Mrs Price’s Complaint 1 was
issued on 6 August 2002. Six separate heads of complaint had been

1. Officer B failed to deal correctly with Mrs Price and her children
relating to issues that arose at the meeting held on 13 March 2001 and

2. Officer F failed to deal correctly with Mrs Price and her children
relating to issues that arose at the meeting held on 13 March 2001 and

The IO considered that these two complaints were substantiated: the IO
identified Officer F as the bearer of the major responsibility for the
shortcomings and also identified Officer B as participating in
responsibility. The IO found that insufficient preparation had been made at
the commencement of the investigation, decisions taken had not been properly
or adequately recorded on the required Form A95 or in the file records; a
joint police/Social Services investigation should have been pursued and was
not, and insufficient preliminary inquiries had been carried out before
speaking to Mrs Price.

3. On 13 March 2002, at Mrs Price’s shop, Officer B made a comment to Mrs
Price’s daughter which was unprofessional, unnecessary and not commensurate
with the facts; This was not substantiated.

4. Officer E had made comments in her Stage 1 report that were untrue or not
based on the facts, that she did not carry out a thorough investigation,
that she had failed to take into account a letter by Mrs Price, that the
investigation was rushed and the report contained lies by Officer F.

The IO considered that this complaint was substantiated in that Officer E’s
report did contain factual inaccuracies and her investigation had not been
thorough, but not substantiated in that there was no evidence that Officer E
had ignored Mrs Price’s letter or that the report had been rushed; and there
was no conclusion in respect of information given by Officer F.

5. Officer C made a statement to the CPC that was not based on facts.

The IO did not consider this complaint to be substantiated; and

6. The Social Care and Housing Department of the Council had convened a CPC
in respect of Mrs Price’s children that was unnecessary.

In view of the decision of the CPC, in the event, to place the children on
the register, the IO considered that the CPC could not be said to have been
unnecessary and this complaint was therefore unsubstantiated, although the
IO concluded that there was no consensus amongst the social workers and Jane
Smith as to the grounds on which the “Section 47 investigation” had been
carried out. The IO’s report identified specific shortcomings in the way in
which Officer A, Officer B and Officer F had acted, particularly in respect
of recording of information and decisions. He identified a series of facts
which had been or could have been known when the social workers visited Mrs
Price on 13 March 2002. Given this knowledge he concluded “It appears
difficult for us to discover why there was the urgency to take action when
the social care staff did or why they took the action they did”. The
overall findings were that there had been fundamental shortcomings in
adherence to procedures and in recording actions; the investigation, which
had been into an alleged criminal offence, should have been carried out
jointly with the police and insufficient inquiries had been carried out
before Mrs Price had been interviewed.

78. The IO made six recommendations in direct response to Mrs Price’s
complaints and five further recommendations ancillary to her complaints.
The recommendations included the review of the respective roles of Officer
F, Officer B and Officer E “under both the Disciplinary and Capability
Procedures” and that an apology be made to Mrs Price indicating that the
recording of the issues relating to the investigation was not to standard,
that some procedures had not been adhered to and that the Stage 1
investigation had not been sufficiently thorough and had reached conclusions
not in keeping with known facts.

79. Officer K, Complaints Officer, wrote to Mrs Price on 12 August
2002 to advise that if she wished to complain about the handling of the CPC
she should in the first instance arrange to meet the chairman of the
conference, as “this would not fall under the normal complaints procedure,
as the conferences have their own procedure for these matters”. Officer H
subsequently, on 14 August, wrote to Mrs Price offering three dates for a
meeting “to discuss your appeal”.

80. Officer I, Head of Child Care Commissioning, wrote to Mrs Price on
19 August 2002 about the investigation of her Complaint 1 at Stage 2. He
apologised for the failures identified in the IO’s report and briefly
referred to action which would be taken to respond to the specific
recommendations. In respect of the recommendations that the roles of three
named members of staff be subject to review under the Disciplinary and
Capability Procedures he undertook that the response “include an
investigation within the internal staffing procedures of the County
Council”. He also undertook to write to Mrs Price again in early October
with a summary of actions taken.

Mrs Price’s Complaint 2

81. Mrs Price and Officer H met on 27 August. On 2 September 2002 Mrs
Price wrote to Officer H requesting an updated copy of the manual and for
the minutes of the CPC. She said she wanted to complain about Officer H
herself and to appeal against the original decision to register her
children. She specified five points of complaint:

1. Officer H’s reneging on the agreement to a two-tier conference

2. The conduct of the conference.

3. Denial of Mrs Price’s and her family’s rights to defend

4. Non-factual reports submitted and accepted.

5. Incorrect relaying of a verbal report on 17 April and failure to
acknowledge a clarifying letter dated 8 July.

82. She asked what further information Officer H required from Mrs
Price to support her claims and requested whatever information she needed to
assist her in her Appeal. She wrote again on 9 September chasing a

83. Mrs Price also wrote again to Jane Smith on 9 September protesting
strongly about the contents of the report she had submitted to the CPC,
challenging specific points and complaining that confidential information
had been shared with the CPC without her permission. She said that,
ironically, as soon as the “professionals” had placed the children’s names
on the register, “any help the children were receiving stopped”. Jane Smith
replied later (25 September) agreeing to certain changes to her report

84. Mrs Price wrote a letter on 10 September enclosing copies of
correspondence concerning her complaints against Social Services and the
chairman of the CPC, Officer H. The intended recipient is not clear from
the copy on the Council’s file but that copy bears a manuscript note
“[Officer K/Officer I] should this issue/complaint be considered by ACPC
rather than through the standard complaints process? [Officer J]”.

85. Mrs Price wrote to Officer J, Head of Social Care and Housing, on 11
September. She referred to a request via her solicitors to postpone the
core assessment of her children until the complaints she was pursuing,
including a complaint against Officer H, had been finalised.

86. Officer H replied to Mrs Price on 11 September 2002. She said she
had not received Mrs Price’s letter of 2 September until 6 September “owing
to [her] work schedule”. She told Mrs Price that her complaint about the
CPC (which I shall refer to as Complaint 2) would be dealt with under Stage
1 in the Council’s Complaints Procedure and that Officer K would contact her
about this “in due course”. She said the Council had insufficient copies
of the All Wales Child Protection Procedures to supply her with one, but she
enclosed a copy of the section relating to complaints and appeals and
confirmed that any appeal against the original decision to register was now
out of time although an appeal could be made against the continuation of
registration and invited Mrs Price to write to her with her specific
reasons. She apologised for the delay in circulating the minutes of the
meeting of 8 July.

87. Mary Brown, Assessment Services Manager with a third-party
organisation, contacted Mrs Price on 12 September to arrange an introductory
visit prior to commencing the Core Assessment. Mrs Price said that she had
asked for a postponement and referred Mary Brown to Officer J. Mary Brown
informed Officer C that she was awaiting his instructions before proceeding.

88. Mrs Price’s solicitors wrote to the Director of Social Care and
Housing on 12 September 2002 making a formal request that the core
assessment of the children be postponed. One of the Council’s solicitors,
Officer N, replied to Mrs Price’s solicitor on 23 September that it was “not
felt appropriate to delay the core assessment pending the resolution of your
client’s various complaints”. These letters were not disclosed to my
investigator for examination during the investigation. Officers were unable
at interview to recall the solicitor’s letter and in a letter dated 18
August 2004 to my investigator Officer I said “I have no recollection of
ever seeing such a letter on any file”. In a further letter dated 8
September 2004 he stated “Officer C confirms my view… that the County
Council did not appear to receive a letter from [Mrs Price’s solicitors].
We would be very interested to know whether you have tracked down this
letter. There appears to be a discrepancy about whether the solicitors were
even instructed to write such a letter”. Mrs Price’s solicitors forwarded
the Council’s reply to her under cover of a letter dated 25 September 2002.
The Council’s reply, declining to delay the assessment, and the solicitor’s
covering letter were later provided to my investigator by Mrs Price.

89. On 17 September 2002 Mrs Price wrote to Officer K reiterating the
complaints she made in her letter to Officer H on 2 September and asking
what she needed to do next to pursue her complaint. Officer K acknowledged
her letter on 20 September and asked her for amplification.

90. Officer I informed Officer J on 18 September 2002 that he was
about to start Mrs Price’s Complaint 2.

The Stage 3 Review Panel for Mrs Price’s Complaint 1

91. A Review Panel met on 24 September 2002 to consider Mrs Price’s
Complaint 1 at Stage 3.

92. The conclusions and recommendations of the IO at Stage 2 were
substantially upheld at Stage 3. However, the panel made no recommendation
in respect of reparation for Mrs Price for the effect that faults on the
Council’s part had had on her and her family. The Panel’s recommendations
were issued on 24 September 2002.

Events September 2002 – October 2002

93. On 26 September the Head of Child Care Commissioning, Officer I,
wrote to Mrs Price in reply to her letter of 11 September addressed to the
Director of Social Care and Housing. He expressed his view that the
concerns expressed in that letter were already being covered in the
complaints processes she had initiated.

94. Mrs Price replied to Officer K’s letter dated 20 September on 27
September explaining the details of her Complaint no 2. She also again
requested a copy of the All-Wales Child Protection Procedures. On the
following day, 28 September, she wrote to Officer I reiterating (inter alia)
her request of 11 September that the core assessment of her children be

95. On 30 September Mrs Price wrote again to Officer J complaining
that her request to have the assessments postponed until the conclusion of
all her complaints had been ignored. She again requested that her complaint
against Officer H be investigated and asked for an appointment with Officer

96. The Director of Social Care and Housing, Officer J, considered the
Review Panel’s findings on Mrs Price’s Complaint 1 and made a brief response
on 7 October 2002. His letter contained no apology and merely stated that
he agreed with the panel’s findings and with the content of Officer I’s
letter to Mrs Price dated 19 August. He did not mention her repeated
request for postponement of a core assessment.

97. On 10 October 2002 Mrs Price again wrote to Officer K expressing
concern that she had been invited to a further CPC chaired by Officer H
although she had made a complaint against her. She received no substantive
reply on this point. Officer K, in her comments on the draft factual part
of this report, states that a response to Mrs Price’s letter dated 10
October 2002 was made on 15 October. This letter however does not address
the question why Mrs Price had been invited back to a conference under the
chairmanship of Officer H when Mrs Price had made a complaint against her.

The second Review Child Protection Conference, 29 October 2002

98. A further CPC was held on 29 October. This, too, was chaired by
Officer H. Officer H told my investigator at interview that it would not be
the Council’s normal practice to withdraw an officer from his or her duties
in respect of a particular client as soon as the client had complained
against him or her, and Mrs Price’s complaint against her had only recently
been received. Mrs Price and Mr Moore were again not permitted to view the
reports until less than an hour before the start of the conference. The
chairman had started the meeting by announcing that the conference was
three-quarters of an hour late starting “due to the time the parents had
spent going through the social worker’s report” (according to the minutes)
and that the professionals present had stated that they had other
commitments to attend to that day.

99. Mr Moore challenged the accuracy of the minutes of the previous
CPC, which had stated that the decision to place the children on the
Register had been unanimous whereas the children’s head teacher had
abstained. The head teacher, who was present, confirmed this.

100. The letter by Mrs Price’s solicitor requesting that the core
assessment of the children be postponed until the outcome of the complaints
procedure had been received was read out.

101. The report prepared by Officer C for the conference records several
actions prescribed by the previous CPC. Mrs Price says none of them had
been carried out: there had been no monthly meetings by the key worker; no
core group meetings; social workers who had been assigned to visit the
family had not done so and Officer C had not provided the relevant sections
of the Child Protection Procedures to Mrs Price. The core assessment had
not been carried out as Mrs Price had been awaiting a response to her appeal
on the matter from Officer J, the Director of Social Services, and although
a reply had been received it had been from Officer N, a Council solicitor,
and there was nothing to indicate that her requests had ever reached the
Director. The report states that when Mrs Price had been approached about
the core assessment of the children “she felt it would be inappropriate at
that time due to ongoing complaints against the Local Authority. It is my
understanding that Mrs Price also wished to seek legal advice”.

102. Mrs Price strongly objected to the report by Officer C which she
felt painted a fictitious picture of improvement. She disputed many of the
statements in the report and felt Officer C was in no position to make
assertions about the family as he had not seen them, apart from on the
previous week, since the last CPC. She was particularly incensed by
reference to the children’s needs being “met in terms of basic care, safety,
emotional warmth and stimulation” in view of their being on the register as
“at risk of emotional harm”.

103. Both Mrs Price and Mr Moore objected strongly to the contents of
the psychologist, Jane Smith’s, report. Mrs Price said that it was not
factual; Mr Moore said it had unfairly selected for inclusion exclusively
negative information about the family and the resulting unbalanced picture
had “put a black cloud over the family”. Officer H insisted however that
“Mr Moore’s perception of the contents was inaccurate” and that “Jane
Smith’s report stood as correct”. Both Mrs Price and Mr Moore felt that
Officer C’s report had been based on Jane Smith’s report and had therefore
perpetuated incorrect information in it. They felt that the CPC had judged
them to be guilty on the basis of an incorrect report despite their

104. Officer D, Officer C’s recently appointed team manager, said she
perceived an improvement in communication between the parents and
recommended that the children’s names be removed from the register and that,
instead, a Child in Need plan be put in place. However, Mrs Price said she
did not want any further intrusion into her or her children’s lives by
Social Services and the only assistance the family required was educational
support for two of the children.

105. A closed session was then held in the conference so that the
Council could take legal advice in view of Mrs Price’s unwillingness to
accept Social Services involvement. When Mr Moore and Mrs Price were
readmitted they were informed that the conference could not recommend
deregistration because Mrs Price had refused to co-operate with input from
Social Care; the child protection plan had not been implemented; and the
fact that the parents had displayed different views in the meeting showed
that they were not working together.

106. Officer C said that the core group meetings had been stopped “due
to the investigation into the complaints made by Mrs Price” (although
attempts had continued to be made to conduct a core assessment despite her
requests to postpone it for the same reason).

107. The conference resolved to retain the children’s names on the

108. Mrs Price wrote to Officer I on 3 November protesting that she had
again not been shown the professionals’ reports until immediately before the

Events November 2002 – February 2003

109. Officer K wrote to inform Mrs Price on 29 November that a Stage 2
investigation of her Complaint 2, about the conduct and chairing of the
first Child Protection Conference, was being initiated but that “due to the
specialist knowledge required the investigation may take more than 28 days”.
Mr Owen, an independent acknowledged expert in child protection procedures,
was commissioned to investigate the complaint on 4 December 2002, ten weeks
after the complaint had been accepted and thirteen weeks after Mrs Price had
first said she wanted to complain about Officer H. Officer I says the
reasons why he commissioned Mr Owen, an out-of-county independent
acknowledged expert in child protection procedures, were that the Area Child
Protection Conference had no authority to investigate anything except the
decision reached by the conference; and that as he was the line manager of
Officer H against whom the complaint had been made, and she was the partner
of the Director, his line manager, he felt it important that the complaint
against Officer H be dealt with independently and objectively. Mr Owen
started his investigation on 19 December 2003. He conducted interviews and
took statements during January 2003. The Council agreed that the third CPC
on 29 October should be included in his investigation.

110. Officer H wrote to Mrs Price on 15 January 2003 informing her that
arrangements for “the meeting” regarding the children had been postponed and
revised arrangements would be sent to her shortly. Mrs Price wrote to the
Council on 19 January 2003 to ask why this had happened.

111. Mrs Price was not satisfied with the thoroughness or accuracy of
the IO (Mr Owen)’s summary of his interview with her and objected in a
letter to Officer K dated 5 February 2003.

112. Mrs Price wrote to Officer J about her Complaint 1 on 4 February
2003. She asked what had happened in respect of the recommendations,
endorsed by the Review panel, that three social workers be subject to review
under the Disciplinary and the Capability procedures, what had changed and
how this had benefited members of the public. Officer I replied on 13
February 2003 referring to his previous letter dated 19 August 2002, in
which he had “outlined tasks to be completed by the beginning of October”.
He confirmed that “all the promised items were followed up” but declined
to go into detail on personnel issues or internal processes.

113. Officer C arranged a core group meeting on 24 February 2003. He
informed Mrs Price of this by letter on 4 February.

The comments of the Investigating Officer at Stage 2 of Mrs Price’s
Complaint 2: February 2003

114. The IO for Mrs Price’s Complaint 2, Mr Owen, wrote to Officer I on
12 February 2003. In his letter he regretted that Mrs Price was
dissatisfied with his investigation. He said he thought that as it seemed
his involvement with the case might now be over it would not be possible to
leave the child protection aspects of the case until the complaint had been
dealt with, as had been envisaged, and set down “the thoughts about [his]
reading of the case so far”. He said:

“I am clear that

Whether the case should have reached a child protection conference is highly

having reached the conference stage in my view the names of the children
should not have been placed on the CP register;

having placed the names of the children on the register removal would have
meant a considerable loss of face on the part of a number of professionals
at subsequent conferences.”

115. Mr Owen explained that his reasons for these conclusions were that
12 months before the initial CPC a strategy meeting had been held to
consider Jane Smith’s child protection referral. The meeting had concluded
that the family should be dealt with as a family in need and that child
protection procedures would be inappropriate. The only “new evidence” since
then was the allegation about the wooden spoon, which had been quickly
discounted “meaning that the position was unchanged from the strategy
meeting 12 months earlier”. Officer H had been unaware of the earlier
strategy meeting, which was referred to in the social worker’s report as “a
professionals’ meeting” which was not the same thing. No-one present at the
CPC who had also been present at the strategy meeting had informed the
chairman of the purpose of the earlier meeting and instead they had
rehearsed the debate from that meeting. The medical reports on Paul
appeared to assume that his bowel problem was behavioural; but it had
existed from a very early age and there was no indication of any evidence to
confirm or eliminate the possibility of a medical problem. Jane Smith and
the successive CPCs appeared to have disregarded an educational
psychologist’s report which confirmed that Paul was dyslexic. He added that
“many of the professionals involved with the parents had…become frustrated
with the family’s attitude but such frustration does not constitute grounds
for placing the names of the children on the CP Register”.

116. Mr Owen added “it is important that the child protection issues are
resolved separately, which in my view means removing the names of the
children from the CP Register and a package of help provided, if the parents
will accept it, to meet the needs of the children”.

117. Officer I replied to Mr Owen on 14 February that Mrs Price was
being asked if she wished to meet Mr Owen again if both parties were

Events February 2003 – May 2003

118. In the meantime, on 18 February 2003, Mrs Price’s solicitor wrote
Officer J to advise that Social Services had that day asked to see one of
the children at night in connection with a letter received on 17 January
from the school about a bruise on his head. Mrs Price had had no objection
but was distressed to think it had taken Social Services a month to respond
to such a letter when the child was on the Child Protection Register. (Mrs
Price herself wrote to Officer J protesting about this on 20 February.) The
solicitor asked why the investigation had taken so long to be initiated and
asked for an appointment to discuss this. The Council’s copy of this letter
has been annotated with a manuscript note: “It seems strange that it’s taken
four weeks to follow up a concern with a child on the Register”.

119. The solicitor wrote on the same day to Officer I advising that Mrs
Price felt it inappropriate, in view of the unresolved complaints, to attend
the core group meeting scheduled for 24 February, and in any case that was
scheduled to be a teacher training day. The solicitor repeated Mrs Price’s
request for a copy of the ACPC Regulations.

120. Officer C compiled a report dated 26 February 2003. The report’s
conclusions include the statements “It would seem… that there is scant
evidence to suggest that these children are at risk of continuing
significant harm” and “My opinion is that the children’s names should be
removed from the Child Protection Register”.

121. Mrs Price made a further complaint in a letter to Officer K dated 3
March 2003. This was about the delay of one month in investigating the
report of a bruise to the head of a child on the Child Protection Register.
An interview with the child had been scheduled for 6 March. Mrs Price’s
letter clearly states “I wish to make a complaint…I want an investigation as
to why when my children have…[had] their names placed on the ‘At Risk
Register’…my son still hasn’t been interviewed.”

122. Also on 3 March Officer I wrote to Mrs Price confirming that he
would not be able to discuss the steps taken in respect of the Review
Panel’s recommendations on her Complaint 1 “in a public forum”. He later
told my investigator that matters relating to staff in connection with
disciplinary processes were confidential; but that the relevant social work
managers had followed up the recommendations and dealt with them directly
with the staff involved within supervisory processes. Officer I added that,
in retrospect, he felt he should not have accepted the recommendation of the
Review Panel for Mrs Price’s Complaint 1 relating to reviewing staff under
the Disciplinary and Capability Procedures.

123. Mrs Price complained to the Ombudsman on 8 March 2003.

Mrs Price’s Complaint 3

124. On 9 May 2003 Mrs Price made a formal complaint to Officer I about
the social worker Officer C. She alleged that he had failed to offer
support, advice or information leading to the CPC on 17 April 2002; that she
had not been sent a record of the Section 47 inquiries; he had failed to
provide her with a copy of his report in good time for the CPC; that he had
failed to provide her with a copy of the notes of his interviews with her
children prior to the conference; that his reports to the CPCs in April and
October had included numerous material inaccuracies, which he should have
checked before including; that he failed to check with participants before
notifying them of a meeting whether the date was convenient; that he failed
to ensure that the agreed plan for the children was implemented; he failed
to carry out a promised visit to Mrs Price for some 6 weeks; he informed the
CPC that Mrs Price refused to have a core assessment carried out, which was
not the case; he had failed properly to schedule a visit prior to compiling
his report to the October CPC; he had failed altogether to keep one
appointment, not at her home, with Mrs Price; he had failed to make
inquiries following an injury to the hand of one of the children while the
child was on the register and he had left a sum of money for Mrs Price
through her letterbox without any note and without asking for a receipt.
She also mentioned various procedural failings: the CPC had not been
convened within 15 working days following the S47 inquiry; the core
assessment had not been carried out within 10 days of the CPC; Mrs Price had
been ignored when she tried to show the CPC chairman proof that she did not
refuse to have the children assessed; she had been given professionals’
reports only immediately before the CPCs and in the case of the October CPC
the conference had had to be delayed in order for her to read the reports.

The Report of the Investigating Officer at Stage 2 of Mrs Price’s Complaint 2

125. The IO, Mr Owen, reported on his investigation of Stage 2 of Mrs
Price’s Complaint 2 (against Officer H) on 2 June 2003. He again stated his
opinion that it had been “highly questionable” that the wooden spoon should
have triggered the initial CPC. He was “very concerned” that so many people
attending the conference, and who had attended the March 2001 meeting, made
no attempt to correct the totally inaccurate description of the meeting in
the social worker report, or inform the chair of the true nature of the
earlier meeting or its conclusion to treat the matter as “need rather than
protection” and he was “extremely concerned” that the CPC discussed in
detail material which had been dealt with at the strategy meeting in March
2001 and reintroduced without any reference to the meeting or accurate
reporting of its contents, and that apart from the (discounted) wooden spoon
incident there had been no new information which could have justified a
different conclusion; hence it had been “totally inappropriate to proceed to
a decision to place the names of the children on the child protection
register”. He commented that there was no evidence to support the
assumption that Paul’s bowel problems were of emotional, not medical, origin
and even if they were, the cause could not be assumed to be emotional abuse.
He expressed concern that Mrs Price’s complaint about the conduct and
outcome of the CPC had not been dealt with within the child protection arena
because it was “out of time” especially as there was no evidence that Mrs
Price had been told until a late stage that she could appeal.

126. With respect to Mrs Price’s specific points of complaint, he was
unable to reach a conclusion on the complaint that Officer H had broken her
agreement to hold the CPC as a two-tier meeting; but he upheld the
complaints that the chairman had failed properly to discharge her
responsibility in relation to preparation of the parents prior to the
initial CPC and the subsequent two conferences. He considered the failure
to submit Jane Smith’s report to Mrs Price in advance had been
“unacceptable”. He upheld the complaints that Mrs Price had not been given
access to the professionals’ reports prior to any of the CPCs. He upheld a
complaint that a report given by telephone by the family’s GP to Officer H
had been inaccurate and that Officer H should, in the conference, have
allowed Mrs Price to produce in evidence a letter from the GP confirming
this. In relation to a complaint that factual inaccuracies in reports and
minutes had not been properly dealt with, he upheld the complaint in that a
conference chairman is required to differentiate between fact, allegation
and opinion and in this case they became confused; nevertheless he added
that “there are some serious questions to be asked of other professionals
about their failure to alert the chair to the existence of the March 2001
strategy meeting” and suggested that the ACPC might wish to consider those
issues further. He believed Officer H had misjudged the information she
was being given by a number of conference members. He concluded that “there
were some questionable practices in play” during the meetings and that Mrs
Price had been treated unfairly, responsibility for which rested with
Officer H. He further commented “The unfairness of the treatment of the
mother is at the core of this complaint. In my view, the evidence was not
available to justify placing the names of the children on the Child
Protection Register… it was as though having failed to have concerns in the
past pursued as child protection, some used or rather misused the
conference, to attempt to ‘get their own way’ and in doing so not only
misled the chair on what had gone before, but also confused opinion with
fact, leading to [Mrs Price] (and also [Mr Moore]) to be treated unfairly…
This case raises some serious matters relating to professional practice
which need some urgent attention…if they have not already done so, then the
local authority should take active steps to remove their names from the
register, unless there is clear evidence to the contrary” (his emphasis).

The third Review Child Protection Conference: 4 June 2003

127. A fourth and final CPC was held on 4 June 2003. This was chaired
by an out-of-county chairman. Jane Smith was not present. The CPC
resolved, by a majority decision, to remove the children’s names from the
register and this was then done.

Events June 2003 –July 2003

128. Officer K wrote to Officer H and Mrs Price on 20 June 2003
enclosing a copy of the Stage 2 report by Mr Owen and asking for comments.
She also copied the report to Officer J.

129. My predecessor as Ombudsman wrote to the Council on 9 July 2003
observing that the statutory complaints procedure had identified
shortcomings on the part of the Council in respect of Mrs Price’s Complaints
1 and 2, and invited the Council to consider offering an appropriate remedy
to Mrs Price for the effect which these shortcomings had had on her and her
family. Emails on the Council’s files show that the Council considered
offering Mrs Price an ex gratia payment although in the event it was decided
not to offer but to “pull the proverbial rabbit out of the hat” if she
should seek a payment. Officers of the Council met Mrs Price and Mr Moore
on 24 July 2003 and the possibility of financial compensation as a remedy
was discussed; Mrs Price was asked to give some thought to quantifying the
loss of her business and a further meeting was arranged for 28 August.

130. Although Officer H had advised Mrs Price before the 29 October 2002
CPC that if the children were not deregistered at that CPC the next CPC
would be convened within a month, and the procedures require that succeeding
conferences should be no more than six months apart, it was over seven
months before the fourth and final CPC was held on 4 June 2003. The delay
was attributed to the need to engage an independent chairman from outside
the county.

131. Officer C’s note, dated 5 June, states that “as the family do not
want input from education and health I suggest the case be closed”.

The Council’s response to the Stage 2 report on Mrs Price’s Complaint 2

132. On 31 July 2003 Officer I made a formal response on behalf of the
Council to the Stage 2 report on Mrs Price’s Complaint 2. The report had
been circulated to the Area CPC, which he chairs. The version which went to
the ACPC was not a full report and was anonymised. Officer I said that an
ACPC meeting would be convened to examine “any implication for multi-agency
working and for the delivery locally of the new procedures… with a practical
action plan”. Officer I acknowledged that it would have been more
appropriate had the complaint been referred for consideration under the
multi-agency auspices of the ACPC rather than the County Council Complaints
Procedure. He observed that it was clear that member agencies of the ACPC
were not addressing the new procedure points about preparation for parents
and children prior to case conferences.

133. He did not, however, concur in the conclusions of the IO as to
failure on the chairman, Officer H’s, part in failing properly to discharge
her responsibility in relation to preparation of the parents prior to the
initial CPC and the subsequent two conferences. He stated that Mrs Price
had spent an hour with Officer H on 11 April 2002 prior to the first CPC;
Officer H confirmed that Mrs Price had been “adequately briefed” and that
this was endorsed by her letter of 9 July 2002. This is not immediately
clear from that letter, which refers to comments Mrs Price made to Officer H
immediately before the conference but does not indicate that there was any
attempt to brief or advise her, and Mrs Price in her reply to Officer I
strongly disputed that the meeting had lasted over an hour or that Officer H
had systematically gone over the area necessary for preparation. Officer I
stated that Mrs Price had refused to discuss any matters with Officer H
prior to the October CPC (ie at a time when she had submitted, twice, a
formal complaint against her).

134. He stated that the Council accepted that Mrs Price and Mr Moore had
not been provided with professionals’ reports before they were submitted to
the CPC but denied that this was the responsibility of the chairman; it was
rather the responsibility of the managers of the professionals concerned,
although he acknowledged that Officer H could have postponed the conferences
to enable the reports to be provided.

135. He stated that the Council did not accept the IO’s conclusions in
respect of the misreporting of verbal reports to the conference: the GP had
not indicated to the conference that the chairman had misreported what he
had told her by telephone and his letter had been read out in full to the
July conference, “as evidenced by the minutes”. (In fact the minutes do not
state that anyone read the letter, in whole or part, aloud to the
conference. They contain the minute “Ms Price said that the Chair had read
a letter from [the GP]” and later “Mrs [Evans] read [the GP’s] letter”. Mrs
Price does not dispute that the letter was read: she says that Officer H
twice refused to read it, then Zoe Evans agreed to read it – but to herself,
not aloud to the conference.) The Council supported Officer H’s reluctance
to challenge information provided by professionals of other disciplines and
said that she had taken steps to clarify issues throughout the conference,
although some inaccuracies had still not been satisfactorily resolved. Mrs
Price disputes that she had taken any such steps.

136. The Council accepted the IO’s conclusion that it was ultimately the
responsibility of the chairman to ensure that a conference was fair in its
handling of a parent but noted that there had been particular complexities
in this case. Officer I confirmed that a different independent chairman had
been commissioned to chair a further review conference; and Mrs Price’s
children’s names were no longer on the register.

137. Mrs Price was confused at receiving this letter at a time when she
had been asked to consider what compensation she sought in respect of the
faults identified in the events which led not only to her Complaint 1 but
also her Complaint 2. She stated her disagreement with the Council’s
response in a letter to Officer I on 4 August and, apparently at a meeting
with Council officers on 28 August 2003, asked for her complaint to be taken
to Stage 3.

The Council’s Stage 1 response to Mrs Price’s Complaint 3

138. Meanwhile, also on 28 August Officer I wrote to Mrs Price about her
Complaint 3 (against Officer C). Mrs Price was under the impression that
this complaint was to be investigated personally by Officer I and not
considered under the formal complaints procedure. Officer K has stated that
Mrs Price had requested that Officer I deal with the complaint. He Officer
I offered explanations, and in two cases apologies, for the shortcomings
identified by Mrs Price. However, he said that:

“the case notes showed that Officer C met Mrs Price on 26 March and 3 April;
some procedural questions were answered during the second meeting; Officer F
discussed the conference with Mrs Price and information relating to CPCs was
sent to her at that time. (Mrs Price disputes these statements.)”

139. It was not practice to send notes of a Section 47 enquiry to
parents; normally parents would be involved in completing the assessment
forms and would then retain copies of the completed assessment.

140. Officer C stated that a copy of his report had been posted to Mrs
Price when she initially requested a copy but as that had not arrived a
second copy was hand-delivered. (Mrs Price disputes this.)

141. Officer C had failed to send Mrs Price his notes of the interviews.
Officer I apologised and offered to send the notes if Mrs Price had not
received them. Mrs Price confirmed she did not now want them. Officer C had
undertaken at a meeting on 3 May 2002 to return within a week but did not
return until 21 June. Officer I also acknowledged and apologised for this.

142. Much of the information in Officer C’s report had been obtained
from information provided by other agencies and a social worker would assume
that specific information provided for such a report would be accurate.
Officer I understood that this issue was being pursued by Mrs Price’s legal
representative and it had not yet been established what the inaccuracies

143. The CPC was not convened within 15 working days and was held 5 days
later than required. However this was the earliest possible date.

144. A core group meeting should have been convened within 10 working
days of the initial CPC. However the failure of “other agencies” to attend
had prevented this; the meetings for May and June had also had to be
cancelled. Meetings were however held in July, August (two meetings) and

145. The Plan was not implemented because it included a core assessment
which did not take place because of “what were perceived as objections from
[Mrs Price]”.

146. Officer I also apologised that the reports for the second Case
Conference on 8 July and the CPC on 29 October had been given to Mrs Price
immediately before the meetings and said the latter was to be discussed at a
special meeting of the ACPC in September 2003.

147. The closed session of the July conference was “partially linked to
[Mrs Price’s] perceived refusal to work with staff in order for the
assessment to be undertaken”; that Officer C said Mrs Price had told him he
could not see her children; and that despite the Council’s commissioning an
independent agency, the assessment was still not initiated.

148. Officer C’s request to see the children before the 29 October 2002
conference had not been at short notice but had been made 12 days before
the conference. Mrs Price queried this and Officer I later apologised and
acknowledged that the visit had been on 24, not 18 October – 3 working days
before the CPC.

149. Officer I apologised for Officer C’s failure to inform Mrs Price
that he would be unable to keep an appointment and thus left her waiting for
three-quarters of an hour.

150. Officer C had been made aware, when he had met her taking her son
to the Accident and Emergency unit to attend to his broken wrist, of where
she was going. He had felt that she was following an appropriate course of
action and his lack of follow-up was in accordance with protocols.

151. Money had been delivered by hand through Mrs Price’s door to enable
her to shop for shoes on the following day. Officer C thought he had
requested a receipt.

Events September 2003 – November 2003

152. Mrs Price contacted the Ombudsman on 9 September 2003. She said
the Council had refused to allow her to be represented or accompanied by her
solicitor at the forthcoming Stage 3 Review Panel hearing. This was in
accordance with the Council’s written procedures but appeared not to be a
requirement of the Representations Procedure (Children) Regulations 1991.
Mrs Price demurred and was told by Officer K the complaints officer that she
(Officer K) would decide whether Mrs Price could be accompanied by her
solicitor but in any event the solicitor was to observe only and not to
represent her client in a legal capacity. Mrs Price was then informed that
she would not after all be allowed to be accompanied by her solicitor. She
was upset that the Council appeared to be arbitrarily denying her the right
to legal advice at this important meeting and objected. In the event her
solicitor was permitted to accompany her.

153. Officer I wrote to Mrs Price on 13 October 2003, conveying his
response at Stage 2 to the complaint she had made against Officer C on 9
May 2003. He agreed that there had been inaccuracies in Officer C’s report
to the April CPC. He said Officer C had tried to gain her agreement to a
core assessment and so had an independent organisation but her “ambivalence
to the undertaking of an assessment became significant and nothing started”.
He stressed that Officer C had acted in good faith.

The Stage 3 Review Panel into Mrs Price’s Complaint 2

154. The Review Panel met on 13 November 2003. The Panel comprised an
independent Chairman, an elected member of the Council and the Council’s
Head of Community Care Commissioning, whose line manager was Officer J. The
Council says that the hearing had been postponed at Mrs Price’s request to
enable Officer H and Mr Owen, the IO, to attend.

155. The panel concluded that the complaints that a promise to hold a
two-tier conference had been broken, and the verbal report from the GP had
been incorrectly reported, were unresolved.

156. In respect of the complaint that no support or information had been
given before the first CPC, the panel concluded that whereas this was
primarily the fault of the authors, the chairman was responsible for
ensuring that the process had been followed and should have adjourned or
postponed the CPC “so that these critical documents could have been
digested”. This had subsequently been accepted by Officer H.

The Panel upheld the following complaints:

* no support or information had been given before the review

* the chairman failed to ensure that the parents had been given
access to reports before their submission to the initial conference,

* the chairman failed to ensure that the parents had been given
access to the reports before their submission to the review conferences,

* the (written) report from the GP was not properly dealt with,

* other factual inaccuracies in reports and minutes were not properly
dealt with; Mrs Price had not been allowed sufficiently to challenge
critical inaccuracies and

* the general handling of the conference by the chairman [was

157. The complaint that the chairman had been unprofessional at the
initial CPC was not, given the (imperfect) information available to her,
upheld. The panel pointed out that responsibility for the outcome of the
conference had lain with both the chair and the authors of the reports and
said that Officer H had subsequently accepted that had she been aware of the
previous strategy meeting held in 2001, she would have dealt differently
with the initial conference, and that with hindsight she would have
adjourned the conference.

158. The panel concluded that the chairman had indeed acted unfairly in
relation to Mrs Price at the initial CPC and commented:

“We too are concerned by the issues that arose within the complaints made by
Mrs Price. They raise fundamental issues about the processes leading up to,
and at the Child Protection Conference and subsequent Reviews…we would want
to make abundantly clear that all possible lessons must be learnt from
[this] unfortunate sequence of events and that a formal plan is adopted to
ensure conclusions are quickly and clearly disseminated to both Social Care
staff and other relevant professional agencies. We also believe that a
properly maintained chronology of events relating to the family would have
proved extremely helpful…”

159. The panel noted that Officer I had expressed his apologies to Mrs
Price “saying that “professional standards had not been as they should have
been” and recommended that the Authority make such an apology formally to
Mrs Price. The members noted also that the minutes of the first CPC declare
that the children should “remain” on the register; they had satisfied
themselves that there had been no previous inclusion on the register and the
minutes were incorrect.

Events November 2003 – mid-2004

160. The Director of Support and Cultural Services, Officer M, was asked
by Officer K, a Council complaints officer, on 18 November to respond to Mrs
Price. He wrote to her on 28 November. He explained that this response was
sent by him and not the Director of Social Care and Housing, Officer J,
because the latter had “declared a personal interest in that he is related
to the Chairperson of the child protection conference”. He said he agreed
with all the recommendations made by the Review Panel and formally
apologised on behalf of the Council that “professional standards have
slipped on this occasion”. He undertook to ensure that the formal action
plan referred to was adopted before the end of the year. He stated that
that was the end of the Department’s Complaints Procedure.

161. A letter from Officer K to Mr Owen, bearing the date 1 December
2002 but filed amongst letters dated 1 December 2003, invites him to “please
find enclosed a copy of a response to Mrs Price from Officer J”. The
corresponding letter however is from Officer M on Officer J’s behalf.
Officer K also sent a copy to Officer J and asked if he required a full copy
of the paperwork.

162. Mrs Price spoke to Officer M on 24 November 2003. His note of the
conversation indicates that it was at this point that it became clear to Mrs
Price that the chairman of the conference, Officer H, was the wife of the
Director of Social Care and Housing, Officer J.

163. Mrs Price remained unsatisfied. She requested copies of the
minutes of the review panel hearing, which had already been refused her (28
November). She also said on 3 December 2003 she wished to proceed with her
Complaint 3 against Officer C, no longer through the informal process
initiated by Officer I but under the complaints procedure at Stage 2. She
asked whether the Council would cover her legal costs. It is not clear to
what costs she was referring. A Council solicitor, Officer L, sought
information about costs incurred. The second letter was marked “Without
Prejudice” and contained the invitation “If you have any concerns or queries
about the term “without prejudice” then please do not hesitate to contact

164. On 11 December 2003 Mrs Price wrote to Officer I confirming that
she wished her Complaint 3 to be investigated in its entirety (he had
suggested that those aspects of Officer C’s actions which had been the
subject of the previously considered complaints should be excluded from
consideration as part of this complaint).

165. Officer L replied on 15 December to Mrs Price’s letter of 10
December. The letter was headed “[Mrs Price] – Complaints against Social
Care and Housing Directorate” and marked “Without Prejudice”. He asked her
to explain why she was sending copies of his correspondence to the Ombudsman
“when my letters are specifically marked without prejudice”.

166. Mrs Price had been copying correspondence to various third parties
including her MP and the Ombudsman. The Council took exception to this as
some of the correspondence had concerned possible payment as a remedy for
the Council’s shortcomings identified by the complaints process and the
Council wished to avoid the impression that it was prepared to make
available compensation. Officer L, the Council’s solicitor, asked Mrs Price
in a letter dated 24 December 2003 to desist from forwarding any further
correspondence to third parties without the Council’s consent. Mrs Price
agreed 11 January that she would refrain from distributing copies to any
recipients other than the Ombudsman.

167. She asked why she had not been informed that Officer H was the wife
of the Director of Social Care and Housing and whether the IO and the review
panel members had been aware of that fact. She wrote to the Chief Executive
of the Council on 13 January asking the same questions and also asked why
she had been informed by one of the social workers that Officer H was a
one-parent family with one child.

168. The Chief Executive replied on 15 January that Officer H’s marital
relationship with Officer J was “not a relevant factor in the exercise of
her professional duties” and that she was not directly managed by him, but
since the Director of Social Services had a decision-making role in the
complaints procedure Officer J had concluded that “undertaking that role
might be perceived as acting with some bias”. He had therefore asked
another Director to act in that capacity.

169. Officer K wrote to Mrs Price on 27 January 2004 advising that the
IO appointed to deal with her Complaint 3 was a manager in another
department of the Council. She informed Mrs Price that the investigation
would cover points relating to Officer C only; would not cover any issues
relating to previous complaints, other members of staff, other directorates,
organisations or agencies. The investigation was scheduled to begin on 2
February 2004 and to be completed on 1 March 2004.

170. Officer L wrote to Mrs Price on 2 February pointing out that she
had been informed of “the position” with respect to Officer H and Officer J
in a letter dated 28 November and asking whether she was suggesting that it
might in any way have influenced the views of the Panel and/or the IO. He
asked when Mrs Price would be able to provide further details of any claims
she might intend making against Social Services.

171. Mrs Price replied on 24 March that she had been advised to request
independent mediation rather than pursue legal action. Officer L replied on
21 April that as far as the Council was concerned the position was that two
meetings had been held, without prejudice, following which the Council had
asked her to provide details of any claims she intended to make against
Social Services. The Council was still awaiting these details and the
question of mediation did not arise.

172. Mrs Price complained to the Children’s Commissioner for Wales.

173. The investigation of Stage 2 of her Complaint 3 was scheduled to
begin on 2 June 2004 but was held in abeyance at Mrs Price’s request as my
investigation of her complaint was by then in train.

What Mrs Price has to say

174. Mrs Price says she and her family have been irrevocably damaged by
the actions of Social Services from March 2002. She says she had felt
terrified and disempowered at the initial CPC where she had been in the
position of someone with no rights or status at all and had had the strong
impression that the professionals present were intent on “doing down” her
family by “deciding what they wanted to be seen as the truth”. Following
the conference and its decision she says she lost the respect and
acquaintance of the mothers of other children at the school, her children’s
teachers and her landlord. Her children were asked by other children at
school whether their mother abused them and their former friends were
discouraged from mixing with them. Mrs Price says she has now been obliged
to remove the children from the school they were attending and place them in
a different school where their emotional and educational needs are better
catered for but the Council refuses to pay for their transport there and

175. Mrs Price says she was so shocked by the events of March and April
2002 that she was unable to focus on anything but exonerating herself,
extricating the family from the grasp of Social Services and reversing the
process which had led to registration. In an effort to understand what had
happened and how it could have led to the registration of her children, she
wrote repeatedly and at length to everyone concerned seeking information
about what had led to the CPC’s decision and asking for assistance. Her
letter-writing became compulsive. She was unable to devote time to playing
with her children or to attend to her retail business, which consequently

176. Mrs Price feels strongly that she has now been demonised within the
Council such that the reaction of Council staff to any approach by her is
negative. The family has been left stigmatised, with no money and no
support for the children. She has failed to obtain help for her children to
attend different schools. She says that the Council regards her as a
vexatious complainant and a nuisance whereas she has simply sought to right
a wrong done to her and her children.

What the Council’s officers have to say

Officer J, Director of Social Care and Housing

177 Officer J confirmed that he was the (statutory) Director of Social
Services. He stated at interview that he had over the period 2002 to 2004
been involved in a significant High Court case and a Joint Review and had
also lost a senior member of staff. He said he had not been aware of Mrs
Price’s case in any great detail and was unable to respond to questions
about the events which led to her complaints. With reference to Mrs Price’s
letters to him and her unanswered request for postponement of a core
assessment until her complaints had been dealt with, he said that his
secretary would have acknowledged and re-routed letters addressed to him and
he had no recollection of Mrs Price’s letters. He said he would not have
felt that postponement was a good idea, nor that it would have been
appropriate for him to have acceded to her request to meet her, as he felt
that was the role of the Head of Service (Officer I). He said he had no idea
when he had become aware that Mrs Price had made a complaint against his
wife (Officer H) although he had been aware that Officer H had chaired the
CPC and had had some dealings with Mrs Price. He said that he was aware
that there had been an issue over what the CPC chairman had been told and
over the respective responsibilities of social workers and managers in
preparation for the CPCs.

178. He said that he had made no reference, in his one letter to Mrs
Price (dated 7 October 2002, informing her of the conclusion of the
statutory complaints process in respect of her complaint 1), to the content
of her previous letters to him because Officer I was responsible for
responding to letters; if no reply was made to any letter he would be
informed by the department’s letter-tracking system. He said his letter to
Mrs Price contained no apology for the faults identified and acknowledged
because the purpose of the letter was to address the recommendation made at
Stage 3 of the complaints process. He said his last active involvement with
Mrs Price had been in writing that letter and he could not recall making
any inquiry as to what had happened subsequently. When asked about the
authority of Mr Officer M, a director in a different department, to
implement Review Panel recommendations which might affect policy and working
practices in the Department of Social Care and Housing, he replied that
Officer M did not have the authority of the statutory Director of Social
Services to implement recommendations but did have authority to implement
corporate decisions; if there should be any disagreement over changes to
working practices the Chief Executive would be able to arbitrate. He said
the situation had never arisen before.

Officer I, Head of Child Care Commissioning

179. Officer I is Officers E and H’s line manager. His line manager is
Officer J, Officer H’s husband. Officer I continues to have line management
responsibility for the post of Child Protection Co-ordinator (previously
held by Officer H). He said at interview that the Social Services
department was “always incredibly busy”, there were usually vacancies and
there was a national shortage of social work managers.

180. Officer I said that he would usually become involved in about 10 or
so individual cases out of an operational caseload of about 600 children.
He had become involved in Mrs Price’s complaint quite quickly. As chairman
of the ACPC any issues related to that would immediately be referred to him.
He explained that under the All-Wales procedures the chairman of the ACPC
could commission an independent review of a decision made by a CPC but the
ACPC’s jurisdiction to investigate was confined to that. He said that this
was the main reason he had commissioned Mr Owen to investigate Mrs Price’s
Complaint 2. He also said that it was particularly important that the
investigation was fair, objective and independent in view of the fact that
he was Officer H’s line manager and Officer J was her partner (later
husband). He said the complaint against Officer H had not been dealt with
at ACPC because the complaint had been against her as chairman and about
alleged maladministration on her part and as he was her line manager he had
taken it upon himself to deal with the complaint against her. The
procedures were not entirely clear on the issue. Since then, however, he had
obtained from Mr Owen a summary of the complaint as a learning tool for the
ACPC and a special meeting had been held. Some of the participant agencies
had been concerned about the summary and a health-led facilitator had been
detailed to look at the issues. The facilitator had however left and
finding another was proving problematic but the intention was to examine the

181. Officer I said that all the recommendations of the Review Panel on
Complaint 1 had been followed up within the context of the supervision
process such that the officers concerned had “conducted a professional
analysis of the mistake that took place”. He said that in retrospect he
might not have accepted the panel’s recommendations in respect of reviewing
individuals under the Disciplinary and Capability Procedures. He did not
believe that the “mistake” had been sufficiently inappropriate for any
disciplinary action to be taken. He said he felt that the outcomes at Stage
2 had not reflected a proper understanding of the social care culture.

182. He could not now recall, the details regarding the considerations
about replacing Officer H as chairman of the CPC after Mrs Price had filed a
complaint against her, but it had been clear to him. that an independent
chairman should be engaged for the final conference. It had taken time to
find an available independent chairman and there was further delay because
of the commitments of this person.

183. He said that letters on operational child care issues addressed to
the Director of Social Services were generally routed to him, although he
thought Officer J read most of the letters addressed to him. He did not
believe Mrs Price’s letters had been treated any differently from anyone
else’s. He was unaware, at the time of interview, that Mrs Price’s repeated
requests for postponement of her children’s core assessment had been
ignored. He later confirmed (see paragraph 88 above) that not only had he
no knowledge of the request but he doubted that Mrs Price’s solicitors had
ever made such a request. In his comments on the draft factual part of this
report, Officer I stated that he had not been directly involved in the
request and had not seen the letter from Mrs Price’s solicitors; he had been
doubtful about the request because he had never seen this letter on file and
he had sought confirmation of this from within the County Council.

184. Officer I had not felt that he was in a difficult position as line
manager to his line manager’s wife against whom a complaint had been made.
The direct management chain between husband and wife, through him, did not
lead to any difficulties in effectively managing Officer H. There had been
no other complaints against her but had there been any problem he would have
gone to another corporate director for advice.

185. He said that the Council had considered making restitution to Mrs
Price in recognition of the panel’s upholding of her Complaint 1 and had
considered the sum of about £1,000. He had asked the legal department to
become involved because he had been committed to resolving her complaint and
had felt it would be helpful to have the lawyers’ input. He thought that
agreement had been within reach: Officer L had written out a resolution and
all parties agreed it, but Mrs Price had initially been focusing on the loss
of her business then it had appeared that the business had been in problems
for some four years, then she “kept moving the goalposts” and no resolution
could be reached.

186. Officer I said that by the time of the final CPC in June 2003 it
had been possible to reach a decision to remove the children’s names from
the register because a national expert (Mr Owen) had said that there was no
reason for them to be on the Register; the evidence from the Health Service
and other evidence was flawed; there was no new evidence; and people had
also become frightened of Mrs Price.

187. Officer I said that he had not realised that staff involved in the
events leading to the complaint had not been allowed to see copies of the IO
Mr Owen’s report until the day before my investigator had interviewed them,
that it had been available on file and they could have seen it. He also
said that chairmen of CPCs had access to the case files before chairing
conferences; whether he or she chose to do so was a matter for the
individual chairman.

Officer H, chairman of the child protection conferences

188. Officer H said that she received an invitation to chair the first
CPC in the usual way from Officer B and Officer F, who also provided a
frontsheet summarising information on the case. This, provided about a week
before the conference, was often the only information she as chairman would
receive about the case. Her responsibilities would include (if the children
were registered) setting a review for a date within 3 months. They did not
include sending information about how to appeal a conference’s decision;
that was the responsibility of the team that convened the conference. She
said that she did, nevertheless, give Mrs Price a copy of the “Child
Protection Procedures” and “Working Together” and talked her through it on
11 April for over an hour. She said that in preparation for the meeting she
should have reports from the contributors to the meeting, although that was
not at the time of the ICPC standard practice and contributions would often
be oral or, if written, submitted on the day. She would speak to the
parents and any children present. She said she had no access to the files
because she had no management responsibility in the case and the history
should be included in the social worker’s report.

189. She said that there had been reference in the social worker’s
report to the ICPC to “a professionals’ meeting” in 2001 but no-one had
indicated that it had been a strategy meeting. Had she known it had been a
strategy meeting she would have focussed the discussion differently and less
emphasis would have been placed on what had gone before.

190. Officer H said that the precise allegation which necessitated the
investigation had become vague. It included the wooden spoon incident but
also concerned emotional harm and had included an argument between the
parents which had frightened the children and during which one of them had
been hurt. She pointed out that the category of registration was “risk of”
not “actual” emotional harm.

191. When asked what difference it had made to the children whether or
not they were registered, she said that key agencies would be able to refer
to the register; a key worker would be allocated and a core group would be
working to implement the Child Protection Action Plan which was designed to
support the family in its protection of the children. There had been “a lot
of liaison between social workers and others in the core group” and the
relationship between Mrs Price and Mr Moore had, according to Officer C,

192. Officer H said that the rule that challenges to a CPC’s decision
have to be made within 21 days appeared to be inflexible. She says Mrs
Price did not indicate that what she wished to do was appeal and her
protests had been vague. Officer H had strongly advised her to seek
deregistration, ie to appeal the decision to keep the children on the
register; she said she had written to Mrs Price offering to accept her
appeal after the 21 day limit had passed but she had already indicated that
she wished to complain against Officer H as chairman.

193. She said that the grounds for keeping the children on the register
were that Mrs Price had refused a core assessment. She had not actually
said that she had asked Officer J to postpone the assessments. She had led
the second CPC to believe that she would co-operate with the core assessment
but before the end of the meeting it had become obvious that she would not.
At the second review conference there had been an attempt to remove them but
it would have involved continuing Social Services involvement. During the
closed session there had been reluctance to consider deregulation because
there were still concerns over the children.

194. Officer H said that at the third CPC in October it had been evident
that someone else would have to be identified to chair the next conference
because “the level of non-verbal animosity was unacceptable”. She says she
discussed this with Officer I. The fourth CPC had been planned for 20
January but she thought it might have taken some time to find an alternative

195. Officer H said that many issues raised by Mr Owen had been taken on
board at ACPC level. It was now more acceptable, for example, to postpone
conferences if reports were not received on time. She said she was no
longer involved in chairing CPCs.

196. Officer H said that she had not discussed the case with her

197. She said that she had found Mrs Price difficult to deal with and
thought everyone involved had found her extremely difficult.

Officer D, Team Manager (as at October 2002)

198. Officer D was Officer C’s line manager at the time of the third CPC
in October 2002 and had been present at the conference. She said that the
grounds for keeping the children on the register at that conference had been
linked to the effect of the parents’ conflict on the emotional development
of the children; Officer C’s plan had been to treat them as children in
need, but not in need of protection. However, the parents had not been
prepared to cooperate with a Children in Need plan so it had been felt
necessary to underpin that with a Children in Need of Protection plan. She
said that although she had suggested at the CPC that the children could be
deregistered, she had changed her mind because she felt a Children in Need
plan would not be implementable.

199. She said she had been interviewed by Mr Owen as part of the
investigation of Mrs Price’s Complaint 2 but had been informed that the
outcome was “for certain people only”. She confirmed that she had seen his
report, for ten minutes only, on the day before she was interviewed by my
investigator, ie on 19 July 2004. It had been only when she had seen
reference to it in the Press and asked for a copy that she had been allowed
to see it. She did not know whether social work staff would normally see IO
reports but she had understood that local authorities should be internally
transparent. She said it would have been helpful to her in delivering
training courses to have known his recommendations at an earlier stage.

Officer C, Senior Social Worker

200. Officer C says that said that he had been asked by Officer F to see
the family with a view to taking the case to the ICPC. He was detailed to
take over the case on 22 March 2002. He had tried to explain to Mrs Price
and her children what would happen next but said that in the initial
meetings he spent time listening to Mrs Price. He said that the allegation
of child abuse which had necessitated the investigation had been the
reference to the wooden spoon being used on the children, which prima facie
might constitute child abuse. He had been satisfied after visiting the
family that there was no physical abuse. However, having witnessed an
argument between Mrs Price and Mr Moore and having been told by one of the
children about the effect their arguments had on the children he thought
there might be some emotional abuse. The conference was there to judge
whether it was of a sufficient level to amount to abuse: a vote would be
taken and the chairman would have the final say. He said that in a
conference of that kind it was difficult to go against a lead: if any
participant said he or she thought the children should be placed on the
register it was difficult for someone else to oppose that and say that he or
she thought they should not be registered.

201. Officer C said that social workers always tried to provide a copy
of their report to the parents before a meeting but in practice, due to
severe pressure of work, the reports were compiled at very short notice,
often the night before, and he had not seen other agencies’ reports at all
before the CPCs. Since Mrs Price’s case however he had had to write to
request other agencies to provide reports well in advance and to ensure that
they were sent to the family. He said that he had been aware of the
difficulties of the case and had tried to be very careful about the
information already on file and to present information, which he
acknowledged was sketchy, in such a way that other agencies would look at it
in a rational light. He had seen the minutes of the strategy meeting in
2001, which included reference to reports of threats to kill. He pointed
out that several of the people at the ICPC had also been at the 2001
strategy meeting, including Jane Smith, the children’s head teacher and the
doctor from the local hospital. The social worker report to the ICPC had
referred to a “professionals’ meeting”. He had not had time to discuss the
report with Mrs Price before the CPC due to pressure of work.

202. Officer C said that when he had contacted Mrs Price to arrange a
core assessment, he had taken a copy of the assessment form with him and
explained that the children should be assessed. He said she had very
clearly not wanted one. He had asked her twice and she had said no. The
procedures now in place made it clear that the social worker is expected to
carry out an assessment; but at that time it had been less clear. He said
he had tried to explain to her but had ended up doing more listening than
talking and thought that Mrs Price had become confused at the difference
between core group and core assessments. No core assessment had in the end
been carried out on the children.

203. Officer C said that social workers, in trying to arrange dates for
meetings, usually tried to co-ordinate place and time to suit the
convenience of participants but problems arose if parents were totally
uncooperative. In such cases core group meetings became quite redundant,
because all the other information could be obtained without the need for a
meeting and participation in the process was meant to be helpful to the
parents. In this case the meeting scheduled for 27 June 2002 had been
called as an emergency because Mrs Price refused to have the children
assessed. A few meetings had been held, but in the end the only
participants were health and education representatives and himself.

204. Officer C said that he believed the original CPC decision had been
made on incomplete information. He had made a different recommendation to
subsequent CPCs because by then he had more information, it was obvious the
children did not want him involved and were quite happy as they were; and
because he had started to form the view that the children were on the
register as the result of an adult conflict between professionals and Mrs
Price such that some professionals had transferred their reaction to Mrs
Price (who could be very critical) on to the children. There was also the
possibility that some professionals had jumped to the wrong conclusion about
the reasons for Mrs Price’s non-cooperation.

205. He confirmed that the reason for the postponement of the fourth CPC
from January to June 2003 had been that an independent chairman was being
sought. He had not seen Mrs Price since the previous October. He said that
he had wanted the children to come off the register, as had been his
recommendation to the October CPC. As far as helping the children was
concerned, in his view the fact that they had been on the register had made
little difference as the things that were going to happen happened anyway
and things that weren’t, didn’t. He said that he had not known that Mr Owen
had included in his recommendation in February 2003 that the children should
come off the register: his report had not been disclosed to social workers
and he had found out about it only when he saw a television programme much
later, in 2004. He said it would have supported his recommendation and made
matters easier for him had he known about it earlier.

206. When asked what support Mrs Price had received throughout the
period covered by the complaint, Officer C said that part of her argument
had been that she did not need support. She had been very capable at child
care and at fighting for her rights and did not need help with those

Officer K, Complaints Officer, Social Care and Housing

207. Officer K is not in the Social Care and Housing Department. She is
directly responsible to the Head of the Policy and Corporate Planning Unit.
She confirmed that because Officer J was involved, as Director of Social
Services, in the final stage of the Social Services Complaints Procedure, it
was not his practice to become involved at an earlier stage so Officer K
would respond to complaints on his behalf. Officer I had probably become
involved in Mrs Price’s Complaint 1 when it passed from Stage 1 to Stage 2.

208. Officer K was aware that Mrs Price had asked for a postponement of
the core assessment of her children; Mrs Price had telephoned her about

209. Officer K said that Mrs Price’s Complaint 2, against Officer H,
never went through Stage 1 but had gone straight for investigation at Stage

210. She was unsure about the legal basis for the Council’s refusal to
let Mrs Price be represented by her solicitor at the Stage 3 review panel
hearing of her Complaint 2. She said she had subsequently discussed the
issue with the legal department and the procedures were to be amended in
light of the expected new National Assembly Complaints Procedures. She
pointed out that in the event Mrs Price had been attended by her solicitor
at that hearing.

211. Officer K confirmed that Mrs Price’s Complaint 3, against Officer
C, had been discontinued as my investigation was expected to encompass the
issues raised.

212. She confirmed that although normally she would notify only Officer
I that a complaint was likely to go to Stage 3 of the complaints procedure,
she had sent Officer J a copy of Mr Owen’s Stage 2 Report on Mrs Price’s
Complaint 2.

Officer K, in her comments on the draft factual part of this report, states
that although copies of the Independent Person (Mr Owen)’s report on Stage 2
of Mrs Price’s Complaint 2 were not distributed, any member of staff
involved could have seen the document.

213. She said it had been difficult to be certain what Mrs Price wanted
as she had appeared to change her mind several times.

Additional Information

214. Mrs Price has, in addition to bringing her complaint about the
actions of Pembrokeshire Social Services to me and to the Children’s
Commissioner, pursued complaints against the actions of the Health and
Education service. She says that in the meantime she has asked for and been
refused assistance with transporting her children to school and the local
authority refuses to reply to her letters and telephone calls. She feels
that she has, because of the vigour with which she has pursued her
complaints, been demonised by the “powers that be” such that no help at all
will be forthcoming for her family.



215. In considering Mrs Price’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 Council’s 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
Price’s 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 Council’s Social Services department with Mrs
Price’s family.

218. I am immediately struck by the difference between Mrs Price’s and
the Council’s 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 Price’s
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 Price’s
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
ham-fisted, manner.

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 Price’s 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 mother’s 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
I’s 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

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 Price’s solicitor to advise her to try to
obtain copies of the social worker’s and the psychologist’s 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
psychologist’s report in advance. I note that Officer C’s report had not
been prepared until shortly before the meeting. However, the psychologist’s
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 psychologist’s 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 psychologist’s 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

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 Price’s 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 Price’s 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 Price’s complaint 1 which were identified by the Investigating
Officer’s 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,

233. Mrs Price’s reason for not accepting Officer C’s 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 C’s 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 Price’s 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
Price’s 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 CPC’s 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 Council’s 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 Council’s
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 Price’s complaint was
maladministration, and caused Mrs Price unnecessary additional time and
trouble in attempting to pursue her complaint through channels which were

239. I regard as maladministration the Council’s failure to replace
Officer H 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 Price’s 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 Price’s and Mr Moore’s
protestations, that the psychologist’s 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 Price’s 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

243. During the time they were on the register of children at risk, Mrs
Price’s 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 Council’s solicitor’s 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 Price’s 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 children’s 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 Price’s 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

Derwen House
Court Road
CF31 1BN

Adam Peat