London borough produced reports and assessments using incorrect information in child protection case, Ombudsman finds

The man behind the complaint, Mr X, complained about how the council considered concerns about his son, Y.

He said the council had access to evidence from multiple medical professionals saying there was no medical evidence to support the suspicion of abuse, but it continued to take child protection action.

Outlining the background to the case, the Ombudsman said Y’s mother, Mrs X, took them to the doctor in May 2024. Y had lesions in a private area.

The family agreed to seek the advice of a paediatrician. The GP reported this to the council as a safeguarding concern on the telephone and then sent a formal referral.

The council noted the telephone call on its care notes. It noted the GP had said “it is unusual to happen at this age group, and commented it could happen via sexual activity”.

The GP’s written referral stated there was a risk of sexual abuse and Y needed “to be assessed fully by a specialist to rule out sexual abuse”.

Three days later, the council recorded the contact on a separate document. The document gave a statement to say Y had lesions which “were” a sexually transmitted infection.

The council noted the family had seen a private paediatrician, who raised no concerns but referred Y to a dermatologist to confirm a diagnosis.

Y then saw a private dermatologist. The dermatologist gave a “suggestive” diagnosis of a common viral infection at an appointment three days later.

At the end of May 2024, the council spoke to the private paediatrician. The doctor said they sent the report to Y’s GP but would need the opinion of the dermatologist.

The council expressed concern there was no definitive medical diagnosis. The council decided to progress the case to a strategy meeting.

The council held the strategy meeting two days later. The report stated the lesions were a sexually transmitted disease. The meeting recorded that the private doctors had not shared their views in writing and needed a further appointment.

The council visited Y and the siblings a week later. Y did not raise any concerns, but their sibling did raise a separate concern. The council completed the assessment for the family.

The following day, the council decided to hold a child protection conference. It recorded this was because of the sexual abuse concerns, and Y’s siblings’ disclosure.

The council held the child protection conference two days later. The minutes noted the lesions “could” be a sexually transmitted infection.

Most professionals said the threshold was not met for a child protection plan as there was no evidence of sexual abuse and there was no formal diagnosis.

The council decided it would offer support to the family under a child in need plan.

At the end of June 2024, the NHS considered the case and detailed it did not have safeguarding concerns. The family sent the report to the council.

The council closed the case in September 2024.

Mr X complained to the council in December 2024. He complained the records and reports contained errors and the council did not arrange for an NHS doctor to see Y.

Considering the complex case, the Ombudsman said: “The council has provided evidence of a case note of the telephone referral and the written referral from the GP. The council is correct to say they differ.

“The case note of the telephone call notes it was unusual for a child to have lesions and it could happen via sexual activity. The written referral said there was a risk of sexual abuse and Y needed to be assessed by a specialist to rule out sexual abuse.

“At no point in the case recording or the written referral did it say Y ‘had’ a sexually transmitted infection. The council wrote this in a document three days after the referral, and in subsequent reports and assessments. This is not an accurate reflection of the referral. This is fault.”

The Ombudsman noted the council would still have considered if there was a risk of sexual abuse, and would still have completed the safeguarding enquiries.

The Ombudsman said: “The council has made multi-agency decisions throughout the case. I cannot comment on the decisions taken in multi-agency meetings. I cannot say the outcome would have been different had the council provided accurate information in its reports and assessments to multi-agency meetings and other professionals.

“However, the council’s initial fault has caused distress and uncertainty. It has caused Mr and Mrs X to ask if it would have been different and if they did not need to go through the distressing process.”

The Ombudsman also described the council’s complaint handling as poor, as Mr X complained in December 2024, but the council did not issue its response until March 2025 - a 44 working day delay.

To remedy the injustice caused, the council was recommended to:

• Apologise to Mr X for the distress and uncertainty caused by inaccurately recording the referral and delayed complaint responses.
• Pay Mr X £500 to recognise the distress and uncertainty the council fault caused.
• Write a letter, to share with Mr X and to place on the children’s case files, accepting and detailing the errors in the Council reports and assessments. Specifically, the referral from the GP did not say Y “had” a sexually transmitted infection.
• Send the letter to any professionals the council sent the incorrect reports and assessments to.
• Produce a plan on how the council will quality assure assessments to ensure they are an accurate reflection of the concerns raised and ensure they are suitably monitored.

The London Borough of Ealing has been approached for comment.

Lottie Winson