Trust’s safeguarding referral
16. In conducting our work, we first establish what should happen by standards, guidance and law then look at what did happen to see how far short the claimed failing falls. Where the level of service or care is not consistent with what we would expect to see, such as a failing, we refer to this as ‘maladministration’ and then go onto look if we can link the injustice and if so, if there are impacts from this.
17. Next, we look at what the organisation has done to acknowledge this or remedy (put right) the failing and finally consider if this is enough. Where we consider the injustice can be linked, and the remedy is not sufficient enough, we may make further recommendations.
18. The relevant guidance is NHS England – Safeguarding. It states all staff, whether they work in a hospital, a care home, in general practice, or in providing community care, and whether they are employed by a public sector, private, or not-for-profit organisation, have a responsibility to safeguard children and adults at risk of abuse or neglect in the NHS.
19. It further explains safeguarding to be protecting a citizen’s health, wellbeing and human rights, enabling them to live free from harm, abuse and neglect.
20. Additionally, the Trust’s policy on Safeguarding Children says NHS providers have a duty under section 11 of the Children Act 2004 to ensure that they consider the need to safeguard and promote the welfare of children when carrying out their role. It says the Trust commits to the principles set out in this Act.
21. Within the policy it is enshrined that staff must notice, ask, listen to the child and family and observe concerns and then have a professional duty to escalate and report concerns to the Local Authority Social Care.
22. Mrs I complains the Trust’s safeguarding referral on 10 January 2024 was inaccurate. She says in her meeting on 10 January the Trust completed a safeguarding referral falsely quoting that Mrs I had said she ‘squeezed’ her ‘baby tightly’. Mrs I says what she actually expressed was that her intrusive thoughts made her feel as though she had acted on these thoughts, which was not the case. She says the Trust’s reporting that she had ‘squeezed’ her baby ‘tightly’ was false and taken out of context.
23. She says the actions of the Trust made her feel terrified of social services, and she now feels extremely paranoid whenever she is around other people. She says she lost her identity, don’t like leaving her home and feels like she failed her children. She also says the actions of the Trust caused her mental distress, panic attacks and flashbacks.
24. In its response the trust says during the session on 10 January, Mrs I completed some questionnaires and afterwards she explained why she had ticked the box ‘I feel like hurting my baby’, where she ‘tearfully shared your past and current thoughts and actions’.
25. The response says Mrs I explained on 8 January she had felt frustrated and when she had put her baby down in his cot, she ‘squeezed him and swore’. The Trust explained it asked further about the squeezing, and Mrs I clarified that she ‘held tightly on his arms’ and then demonstrated what she did. The response says Mrs I advised her baby was alright and there was no bruising, but she had felt guilty.
26. The Trust response also says it called Mrs I later that day prior to submitting the referral to Children’s Services, having discussed it first with the wider team and the Trust’s local safeguarding team. The Trust explained the referral documented what Mrs I had said in the appointment, information about her own mental health, the treatments she was engaging with, and the support she had from family.
27. The Trust apologised Mrs I felt the information was inaccurate and acknowledged this was an extremely upsetting and distressing time for Mrs I and her family. It further acknowledged that the referrer and the parent may sometimes have different recollections or views on the information shared.
28. Finally, the Trust explained with what Mrs I had said during the appointment and what she had demonstrated, it had no alternative other than to discuss this with the multi-disciplinary team (MDT) and act on their advice to contact the Trust’s Safeguarding team. Subsequently, they followed the Trust’s safeguarding guidance and had contacted the safeguarding team for further advice.
29. A multidisciplinary team is a group of professionals from a variety of backgrounds working together with a shared goal of providing effective care and support.
30. From the Trust policy we know in a multi-agency safeguarding approach (MASH) the Trust is obliged to work with other agencies at all levels of the organisation to protect children from harm or to address allegations of potential harm or risk. Staff must make a referral to Children’s Social Care if there are any concerns or signs that a child under the age of eighteen or an unborn baby may be experiencing or may have already experienced abuse or neglect.
31. In doing so, the Trust are not saying abuse has occurred but following a safeguarding agency approach to raise a concern to those that would then consider and look in depth. Often this can result in a referral being ‘stood down’ and no further action taken. Staff should gain consent from those with parental responsibility to make the referral unless this will increase the risks to the child, in those cases they would.
32. We can see the Trust explained their intent before the referral which follows this part of the Trust’s own policy.
33. It is not for us to say whether a Trust should or should not make a referral other than to consider if the administration of this process was followed. Similarly, we were not present at the time of what was spoken, said or nuanced and therefore cannot take a view. Even if we were present, what remains is that the Ombudsman is not able to say what constitutes safeguarding concerns. Our role is to establish whether the right procedure was followed.
34. From the information provided by the Trust, we can see from a multi-disciplinary team (MDT) it was escalated to the relevant person(s), then discussed and that was then passed onto the local authority.
35. Point 4.18 of the Trust policy says staff must seek advice and support from their clinical team and/or Line Manager when they are worried about a child.
36. We know the Trust discussed matters with the ‘wider team’ and the Trust’s safeguarding team and then called Mrs I to informed her about the referral. This is in line with the Trust’s policy.
37. We recognise Mrs I contests what was said during the appointment on 10 January.
38. We have seen the Trust felt there was a need to discuss a concern regarding child safety with its wider team and following this discussion to raise a child safety referral to the local authority.
39. This is in line with the Trust’s policy and the NHS England – Safeguarding guidance which say all staff have a responsibility to safeguard children at risk of abuse or neglect in the NHS.
40. We recognise how distressing these events were for Mrs I and her family. We do not underestimate the impact this has had on her. We do not wish to take away from her views and feelings on this matter.
41. We have seen the Trust acted in line with the relevant guidance and have seen no indication of a failing in the actions of the Trust. Therefore, we will take further action.
The Trust did not provide Mrs I with any support after the safeguarding referral
42. We note there are no national guidelines on providing parental support after a safeguarding referral such as emotional, physical or spiritual support.
43. We contacted the Trust to ask if it has any guidelines covering patient care post safeguarding. The Trust confirmed it does not have a specific policy for patients care post safeguarding, however it said services were in contact with Mrs I following the safeguarding referral.
44. Mrs I said following the safeguarding referral the Trust did not provide her with any support. She says the Trust should have contacted her at least every few days to see how she was doing. She says the Trust did not call her for six weeks after the case was closed with social services.
45. Mrs I says the Trust did not contact her when the case was open with the social services. She says she cried every single day, felt alone and hurt.
46. In its response the Trust recognised how difficult this situation was for Mrs I. The Trust said there were a number of planned contacts with various staff members from the Perinatal team between 11 January 2024 – the day after the referral was made and 11 March 2024.
47. It said Mrs I’s care coordinator contracted children’s services about the referral on a few occasions following this having been made and an email received by the Trust on 29 February 2204 advised they were about to close the case.
48. The Trust said Mrs I was seen regularly by the team and the family therapist after the referral was closed on 25 March 2024. The Trust said her contact with the team was reduced carefully and she was discharged from the team in October 2024.
49. We recognise how difficult it was for Mrs I and appreciate this was a very difficult and challenging time for her and her family.
50. As we noted before there are no national guidelines on providing parental support after a safeguarding referral. Therefore, we cannot say there is an indication of failing as the Trust has no duty regarding this matter and we cannot say maladministration/failing has occurred.
51. Therefore, we will take no further action.
52. This marks the end of our consideration of this complaint.