Children with special needs and disabilities were not prioritised by Liverpool City Council quickly enough after the 2014 reforms, with poorly set outcomes and insufficient multi-agency working, according to the joint local area SEND inspection by Ofsted and the Care Quality Commission, published this month.
In one case, a senior health professional signed off a plan which held the community paediatrician responsible for a child's access to the curriculum and helping them to achieve their academic potential.
Some parents told inspectors that the starting point when accessing the system is a "no", according to a letter detailing the findings to director of children's services Steve Reddy, whose department was issued with a "requires improvement" rating by Ofsted last year.
For these parents: "this is the beginning of a long and arduous fight to get their children's needs met", adds the letter.
It continues: "While some parents have had nothing but positive experiences; the opposite has been the reality for many."
Aspects of the arrangements were found to be contravening Department for Education guidance.
Almost half of all EHC plans needing to be amended were beyond the statutory eight-week timescale and it was "not uncommon" for plans to be two or three years out of date.
"This renders the EHC plans meaningless and removes accountability and responsibility to meet children's needs from professionals," the report states.
Inspectors reported delays hampering support for children across services, including within paediatrics, pathways for autism spectrum disorder and attention deficit hyperactivity disorder, youth justice, occupational therapy, and wheelchair services.
They also said that within education, children with an EHC plan were not making good progress, with the trend "worsening" and that children and young people with SEND were the group most likely to be permanently excluded from schools.
Inspectors also highlighted how decisions about assessments for an EHC plan are "contrary to the fundamental principle of joint working", as they are made by just two people, instead of the panel being made up of "multi-agency professionals".
The letter adds: "Leaders are clear about the shortcomings in SEND provision in the city and how far behind they are in implementing the reforms of 2014.
"The action plans that sit beneath the SEND strategy demonstrate the immaturity of implementation.
"While leaders have known of long-standing issues, too much time elapsed before the necessary action and focus was given to children and young people with SEND.
"Leaders have not taken the swift and remedial action necessary."
Inspectors did find good practice in several areas, including within the parent and carer forum, LivPac, which is credited with making "significant progress" over the past two to three years.
They also praised SEND champions in each service within social care, which inspectors said ensured specialist knowledge was kept up to date, and pointed to "dedicated professionals" within the authority who were "working tirelessly" for children and their families to meet needs despite the challenging circumstances.
The letter asks for a written statement of action is produced, setting out plans to improve.
In a statement, Reddy acknowledged that for some families "we need our response to be much improved".
He added: "Unlike some other areas, inspectors noted the area's own self-assessment was clear on what needs to change.
"The council and partners are committed to working with children and families to ensure we listen and improve our response."
He added that nationally, more than 50 per cent of the SEND area inspections have resulted in the requirement of a "statement of written action", and highlighted a need for extra funding to cater for a "significant rise in demand" for SEND services.