Physical examination on 11 June 2024
19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and we have not found any indication the Trust acted inappropriately or unfairly by physically examining K on 11 June 2024.
20. Mr H says he withdrew consent for the involvement of SNSN on 23 May 2024. He says the Trust therefore acted inappropriately and unfairly by physically examining his son, K, on 11 June.
21. The Trust’s ‘Failed contacts and disengagement in relation to children’ procedure says families who choose to decline the provision of the service should be asked if they would put their request in writing.
22. Our Principles of Good Administration say organisations should follow their own policy and procedural guidance, whether published or internal. They say organisations should behave helpfully, dealing with people promptly, within reasonable timescales, and they should communicate effectively, using clear language that people can understand and that is appropriate to them and their circumstances.
23. The records show Mr H emailed K’s Headteacher on 23 May to withdraw consent for SNSN involvement. After speaking to the SNSN service, the Headteacher emailed Mr H on 24 May asking him to put the request in writing to a specific email address to be actioned by the SNSN service.
24. On 11 June, the records indicate the community paediatrician contacted Mr H and explained they would be examining K that day. This was a follow-up appointment that had also been communicated previously to Mr H by letter on 16 May. It appears that Mr H did not refuse this or tell them that consent had already been withdrawn and not to go ahead with the examination.
25. The records show Mrs H emailed the specified email address for the SNSN service on 12 June. This was to formally withdraw consent for SNSN involvement with the family.
26. The records indicate the Trust actioned this request the same day and there is nothing to indicate that SNSN staff had any involvement with K, or any of Mr H’s other children, from this date.
27. Taking everything into account, we consider the Trust acted in line with its ‘Failed contacts and disengagement in relation to children’ procedure by asking Mr H to put his request in writing for it to be actioned by the SNSN service. It therefore also acted in line with Our Principles of Good Administration by following its own procedure.
28. We understand Mr H was unhappy that SNSN staff was present at the appointment on 11 June. However, we can see that his request was not put in writing to the SNSN service until 12 June, a day after this appointment. We can see the Trust actioned this request promptly the same day. We consider this is in line with Our Principles of Good Administration.
29. Therefore, we have not seen any indications of failings in the Trust examining K on 11 June 2024 as formal withdrawal of consent had not been given at this stage.
Safeguarding referral submission
30. Mr H says the Trust inappropriately put in a safeguarding referral to the local authority without notifying him or his wife. He says he has lost trust in local NHS services and the safeguarding referral has caused lasting reputational damage and exposed his family to unnecessary scrutiny by external agencies.
31. The Trust’s ‘Failed contacts and disengagement in relation to children’ procedure says that if a family declines the provision of its service then it should be recorded on the chronology and any welfare concerns should be discussed with a team leader and the other agencies involved as appropriate.
32. The records indicate the school nurse had been involved with the family for approximately eight years and that their concerns around K’s health and wellbeing had been growing for a while. The family’s withdrawal of consent for the service on 12 June added to their concerns.
33. On 17 June, the school nurse discussed their ongoing concerns with their team leader and the safeguarding team leader. Discussions were had around historical concerns and the recent concerns, which included the withdrawal of consent on 12 June, K’s absence from school from 11 June, and the 17 June missed blood test appointment.
34. The records show that the staff agreed that if K did not attend his next medical appointment on 24 June, then a safeguarding referral to the local authority would be put in. This is because it would further demonstrate that K was being isolated from professionals and would raise more concerns about his ongoing health and wellbeing.
35. We consider the Trust acted in line with its ‘Failed contacts and disengagement in relation to children’ procedure by discussing the concerns it had about K’s health and welfare. It therefore also acted in line with Our Principles of Good Administration (above) by following its own procedure.
36. The Trust’s ‘Safeguarding children and adults’ policy and procedure says its staff have a duty of care to act on concerns about a child’s welfare. If staff have safeguarding concerns that a child is at risk of or is suffering significant harm, they must refer to the local authority as the safety of the child is paramount.
37. The policy also says professionals should discuss any concerns with the family and seek consent to make a referral unless they have concerns that doing so would place a child at increased risk of further harm. When parental consent is not gained, the reasons for the decision must be documented in the records and confirmed in the written referral.
38. On 24 June, the Trust received an email to say Mr H had cancelled K’s appointment as they were returning that day from holiday. It also informed the Trust that K would be going on holiday again on 7 July for a month.
39. This further missed medical appointment prompted the Trust to put in the safeguarding referral to the local authority as agreed during the discussion on 17 June. It decided not to inform K’s parents before doing so as it deemed this could increase K’s risk of harm.
40. The referral states that the relationship between the school nurse and the family was strained. The school nurse was worried that the family may abscond to Spain if they found out about the referral. Also, as the family had recently withdrawn consent for SNSN to be involved, contact was not considered appropriate.
41. Our adviser says that it is always best practice to inform the parents when making a safeguarding referral. However, it has to be the referrers responsibility to weigh up the benefits and risks involved in doing so. The school nurse had working knowledge of the situation and had concerns about the parent’s potential to disengage from health professionals, leaving the child even more vulnerable. Therefore, they made a decision not to notify K’s parents before submitting the referral. The reasons for this decision were justified and clearly documented on the referral.
42. The Trust says a child's welfare is the primary concern, and making a referral does not necessarily mean that immediate or drastic action will be taken against the parent. Instead, it considers this to be a step towards ensuring that the child receives the care and support they need.
43. Having taken everything into account, we consider the Trust acted in line with its ‘Safeguarding children and adults’ policy and procedure and Our Principles of Good Administration by submitting a safeguarding referral as it had a duty of care and a responsibility to act on the concerns it had.
44. We also consider the decision not to inform K’s parents prior to submitting the referral was in line with the procedure and Our Principles. This is because the Trust had concerns that doing so would place K at increased risk of further harm and clearly documented these reasons in the referral.
45. We have not seen any indications of failings in relation to the referral, as such we will not be taking any further action on this part of the complaint.
46. This decision is not intended to underestimate the distress and upset it caused Mr H and his wife when they found out about the referral.
Safeguarding referral contents
47. Mr H says the safeguarding referral misrepresented clinical facts and portrayed his family as uncooperative.
48. In the complaint responses, the Trust acknowledged that it did not make it clear between established fact and the referrers opinion in the referral form it submitted to the local authority. As the Trust has already acknowledged a failing in this area, we have gone on to look at what impact this had and whether this has already been remedied.
49. Mr H considers the referral has caused lasting reputational damage and exposed his family to unnecessary scrutiny by external agencies. However, as we consider it was appropriate for the Trust to submit the safeguarding referral, we cannot consider this as an impact. The involvement of the local authority would have happened anyway because it has a duty to investigate any referral it receives. Further, there is nothing to indicate the information contained in the referral has caused lasting reputational damage to Mr H and his family. Therefore, we cannot link this impact.
50. We consider the information in the referral caused distress and upset to Mr and Mrs H. As we have identified an impact, we must go on to see whether the organisation has done enough to put things right.
51. Our NHS Complaints Standards says when poor service is identified organisations should offer fair remedies to put things right. Organisations should acknowledge and apologise for the poor service and for the impact it had. Organisations should also look for continuous improvement and learn lessons from complaints to make sure it is not repeated.
52. In its complaint responses, the Trust apologised for the information provided in the referral and in its record keeping and acknowledged the upset and distress this caused Mr and Mrs H. It said it recognises the importance of accurate and sensitive communication and has taken action to ensure this critical responsibility is shared with its staff to prevent it happening again.
53. To decide whether a financial remedy is appropriate, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale (SOIS). Following this review, we consider the injustice falls under level one of our SOIS. This is for injustices, such as distress and upset, following a single instance of poor service. This level does not meet the criteria for financial payment.
54. Taking everything into account, we consider the Trust has acted in line with our NHS Complaint Standards. This is because it has apologised for its poor service and acknowledged the impact it had. It has also taken learning from the complaint to improve its service going forward. We consider this is enough to put things right. Therefore, we will not be taking any further action.
Complaint handling
55. Mr H says the Trust’s complaint handling was not impartial. He says it disregarded key evidence and gave contradictory, conflicted, and unfounded complaint responses.
56. The Trust provided its initial response on 19 July 2024.
57. On 28 July and 3 August, Mr H sent further information to show why he was dissatisfied with its response.
58. The Trust provided a further response to Mr H on 13 September to clarify and expand on its explanations and to address the additional points Mr H had raised.
59. Mr H remained dissatisfied and contacted the Trust again on 16 September to outline his outstanding concerns.
60. On 31 January 2025, the Trust agreed to hold a multi-disciplinary panel to independently review the evidence Mr H had provided and to ensure it had responded to all the points he had raised.
61. On 25 April, the Trust wrote to Mr H to inform him of the panel’s decision. The outcome was that there was nothing to indicate there were any further shortcomings other than what had been identified in its earlier responses and confirmed action had already been taken. The Trust confirmed there was nothing outstanding that it needed to add and considered this to be its final response.
62. Our NHS Complaint Standards say that an effective complaint handling system makes sure staff take a thorough, proportionate, and balanced look into the issues raised in a complaint. It gives people fair and open answers to their questions, and takes full accountability for mistakes identified.
63. We can see that each time Mr H raised issues with the Trust’s response it responded to these concerns and expanded on its explanations. It also organised an independent review of the response and explained to Mr H what this panel had concluded. We consider this is in line with Our NHS Complaint Standards.
64. As outlined above, the Trust accepted one element of poor service it provided. It apologised to Mr H and acknowledged the impact this had. It also took action to ensure the poor service is not repeated. We also consider this to be in line with our NHS Complaint Standards.
65. As a result, we have not seen any indication that the Trust’s complaint handling lacked impartiality or that it did not consider the information Mr H provided. Therefore, we will not be taking any further action.
66. We understand the distress it caused Mr and Mrs H having felt that their concerns were dismissed throughout the complaint process. We hope our consideration of the complaint has reassured them that this was not the case.